TEEATISE ON INSANITY 



ra its 



MEDICAL RELATIONS. 







WILLIAM A 1 .' HAMMOND, M. D., 

SUEGEON-GEXEEAL UNITED STATES ARMY (RETIRED LIST) ; PROFESSOR OF DISEA8E8 OF THE MIND AND 

NERVOUS SYSTEM, IN THE NEW YORK POST-GRADUATE MEDICAL SCHOOL; PRESIDENT OF 

THE AMERICAN NEUROLOGICAL ASSOCIATION, ETC., ETC. 



* 



0- 



>' 




MAY1C 1833' 



Fructu, nonfoUis arbor em cestima. 



NEW YOEK: 
D. APPLETON AND COMPANY, 

1, 3, and 5 BOND STEEET. 

1883. 



,H3 



COrTEIGHT BY 

D. APPLETON AND COMPANY, 



I DEDICATE THIS BOOK 
TO 

. J. S. JEWELL, M. D., 

PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE CHICAGO MEDICAL COLLEGE, 

WHOSE LEAENING 

HAS ALWAYS COMMANDED MY HEAETIEST ADMIEATION, 

AND WHOSE FEIENDSHIP 

IS ONE OF THE GEEATEST PLEASUEES OF MY LIFE. 



PEEFAOE 



In presenting to the medical profession a new work on the 
subject of Insanity, it seems proper that I should state the 
reasons which have induced me to add another volume to the 
store of medico-psychological literature, and to point out 
briefly what are, I think, distinctive features of the present 
production. 

I have long been convinced that the term "insanity " has 
hitherto been applied in altogether too limited and illogical a 
manner. It has been understood, both in and out of the pro- 
fession, that a person, in order to be considered the subject of 
mental aberration, must, at some time or other, present cer- 
tain marked symptoms, which he cannot avoid exhibiting, 
and which are sufficient to indicate to the world that he is 
not in his right mind. 

Starting from the points that all normal mental phenom- 
ena are the result of the action of a healthy brain, and that 
all abnormal manifestations of mind are the result of the 
functionation of a diseased or deranged brain., I do not see 
why these latter should not be included under the designa- 
tion of "insanity," as much as the former are embraced 
under the term "sanity." There can be no middle ground, 
for the brain is either in a healthy or in an unhealthy condi- 
tion. If healthy, the product of its action is " sanity ; " if un- 
healthy, "insanity." 

Of course, very little of such insanity comes under the sig- 
nification given to the word by lawyers and the public gen- 



vi PREFACE. 

erally. But legal insanity and medical insanity are very 
different things, and the two standards can never and ought 
never to be the same. The law establishes an arbitrary and 
unscientific line, and declares that every act performed on one 
side of this line is the act of a sane mind, while all acts done 
on the other side result from insane minds. This line may be 
in one place to-day, and in an entirely different place to-mor- 
row, at the whim or caprice of a Legislature ; it may be estab- 
lished on a certain parallel in one country, an$. on an entirely 
different parallel in another country. In the State of New 
York, for instance, it is drawn at the knowledge of right and 
wrong; and perhaps, all things considered, this is about as 
correct a legal line as a due regard for the safety of society 
will permit to be made. But every physician knows that it is 
absolutely untenable from his point of view ; that it is not a 
medical line, and that there are thousands of lunatics insane 
enough to believe themselves to be veritable Julius Caesars, 
and yet sufficiently sane to know that a particular act is con- 
trary to law, and to be fully aware of the nature and conse- 
quences of such act. Hence it follows that, from a medical 
stand-point, there is no middle ground between sanity and in- 
sanity. The line of demarkation is sharply drawn, and it is 
but a step from one territory to the other. There is a large 
proportion of the population of every civilized community 
composed of individuals whose insanity is known only to 
themselves, and perhaps to some of those who are in intimate 
social relations with them, who have lost none of their rights, 
privileges, or responsibilities as citizens, who transact their 
business with fidelity and accuracy, and yet who are as truly 
insane, though in a less degree, as the most furious maniac 
who dashes his head against the stone- walls of his cell. To 
many of these persons life is a burden they would willingly 
throw off, if death concerned them alone, for they are pain- 
fully conscious of their actual suffering, and morbidly appre- 
hensive in regard to the future. There are very few people 
who have not at some time or other, perhaps for a moment 
only, been medically insane. It is time, therefore, that the 



PREFACE. vii 

horror of the word should be dissipated, and that the fact 
should be recognized and acted upon, that a disordered mind 
is just as surely the result of a. disordered brain as dyspep- 
sia is of a deranged stomach ; that a scarcely appreciable 
increase or diminution of the blood-supply to the brain will 
lead as surely to mental derangement of some kind as an 
apparently insignificant change of the muscular tissue of the 
heart to fat, will lead to a derangement of the circulation, 
and that in the one case there may be a hallucination, a de- 
lusion, a morbid impulse, or a paralysis of the will, just as 
in the other there, may be an intermittent pulse, a vertigo, 
or a fainting-fit. There is no more disgrace to be attached to 
the one condition than to the other. 

To some of the states of mental aberration which are thus, 
I think, properly to be classed as insanities, I have endeav- 
ored to draw attention, to point out their clinical features, and 
to indicate the treatment proper for them. So far as I know, 
this is the first systematic attempt in this direction, and some 
of the forms — though many physicians will recognize them as 
old acquaintances they have met with in their practice — are 
now described for the first time. 

Again, the alienistic physician, whose practice is not re- 
stricted to a lunatic asylum, has peculiar facilities for study- 
ing insanity in its first and most curable stages. There are 
many varieties of mental derangement of which asylum phy- 
sicians never see the beginning ; and there are others, not re- 
quiring the restraint of an institution of the kind, which they 
never see at all. The day has gone by when they were looked 
upon as the sole exponents of psychological medicine, and in 
all parts of the civilized world the greatest advances in that 
division of the healing science and art are made by physi- 
cians who are unconnected with asylums. 

I have devoted a whole section of this work to the consid- 
eration of sleep and some of its derangements, and am in- 
debted to Messrs. J. B. Lippincott & Co., of Philadelphia, 
the publishers of a little book of mine on the subject, 1 for per- 

1 " On Sleep and its Derangements," Philadelphia, J. B. Lippincott & Co. 
1 



viii PREFACE. 

mission to incorporate some of its chapters into the present 
volume. I think that a knowledge of the physiology and 
pathology of this function should form the groundwork of 
the study of insanity. It is in aberrations of sleep that we 
often find the first indications of aberrations of mind. 

I am also greatly indebted to Dr. R. L. Parsons, late the 
Medical Superintendent of the New York City Lunatic Asy- 
lum, for the use of his voluminous case-books of patients in 
that institution while it was under his charge. The perusal 
of these records has been of great assistance to me in my de- 
scriptions of several of the forms of insanity. 

Again, a word in regard to the classification adopted. In 
the present state of the patho-anatomy of insanity, a classi- 
fication, based, as it should be, on the essential morbid condi- 
tions giving rise to the symptoms, cannot be made. There are 
indications, however, that vaso-motor disturbances, by which 
the amount of intracranial blood is altered either by increase 
or diminution, are the starting-point at least of almost every 
known form of mental derangement. In his recent work on 
Insanity, Luys * adopts this view — a view which, I may say, 
has long been held, though not so thoroughly worked out, by 
the author of the present volume, and which he has enunciated 
in several monographs and treatises. 2 It is in this direction 
that we are to look for the data on which to found a correct 
system. of psychological pathology and a true classification. 

In the mean time every author arranges the varieties which 
he differentiates, to suit himself, and at once with entire con- 
sistency proceeds to point out the fallacies and shortcomings 
of other systems. A classification such as can be made at 

1 "Traite clinique et pratique des maladies mentales," Paris, 1881. 

2 '" On Wakefulness," New York Medical Journal, 1865. 

"Sleep and its Derangements," Philadelphia, 1869. 

" On some of the Effects of Excessive Intellectual Exertion," Bellevue and 
Charity Hospital Eeports, New York, 1870. 

" A Treatise on the Diseases of the Nervous System," New York, 1871, and 
subsequent editions to seventh, 1881. 

" Cerebral Hyperemia, the Kesult of Mental Strain and Emotional Disturb- 
ance," New York, 1879. 

" On Certain Conditions of Nervous Derangement," New York, 1881. 



PREFACE. ix 

present can pretend to no more than to arrange the several 
forms of mental derangement into groups, possessing some 
one prominent feature in common. Whatever may be the 
objections to the system I have proposed in this work — and 
that they are many, no one knows better than I do myself — 
I hope and believe that it will prove of assistance to the stu- 
dent desirous of investigating the phenomena of insanity. If 
this expectation is only partially fulfilled, I shall be amply 
satisfied. 

Finally, ' the objection may be made that, not being the 
superintendent of a lunatic asylum, I have no business to set 
up as an authority on insanity, much less to write a book on' 
the subject. To any raising that point I would say that for 
the last seventeen years I have been a teacher on the subject 
of " Diseases of the Mind and Nervous System " in four medi- 
cal colleges of the city of New York, three of them among 
the largest in the United States, and one the course of in- 
struction in which is given to physicians only. The first pro- 
fessorship of that branch of medical science in this country 
was held by me ; and, furthermore, that, though I cannot 
claim to have seen so many cases of insanity as the average 
superintendent of an asylum with its thousand inmates, I do 
claim that a single case thoroughly studied is worth more as 
a lesson than a hundred that are simply looked at, and often 
from afar off. The medical student who dissects one human 
body is likely to learn more of anatomy than the janitor who 
sees hundreds of corpses brought to the dissecting-room. 

43 West Fifty-foueth Steeet, 
New Yoek, May i, 1883. 



COlsTTEl^TS. 



SECTION I. 



o 

15 



GENERAL PRINCIPLES OF TEE PHYSIOLOGY AND PATHOLOGY OF THE 
HUMAN MIND. 

CHAP. I 

I. ISTatube and Seat of the Mind ..... 

II. Divisions of Mind ...... 

1. Perception.— 2. The Intellect.— 3. The Emotions. — 1. The Will 

III. Geneeal Remaeks on the Mental and Physical Conditions 
Inheeent in the Individual which Influence the Action 

of the Mind ....... 34 

IY. Eccenteicity ....... 38 

V. Idiosynceasy ........ 43 

VI. Genius ........ 48 

VII. Habit. ........ 51 

VIII. Temperament ....... 60 

IX. Constitution ........ 72 

X. Heeeditaey Tendency ...... 75 

XI. Age ......... 88 

XII. Sex 101 

XIII. Race 117 



SECTION II. 

INSTINCT: ITS NATURE AND SEAT. 



I. The Nature of Instinct 
II. The Seat of Instinct 



122 
143 



Xll 



CONTENTS. 



SECTION III 



chap. SLEEP. 

I. The Causes of Sleep . 

II. The Necessity foe Sleep . 

III. The Physical Phenomena of Sleep . 

IV. The State of the Mind dueinc Sleep 
V. The Physiology of Deeams 

YI. Moebid Dreams 



PAGE 

151 
174 
178 
183 
210 
234 



SECTION IV. 



DESCRIPTION AND TREATMENT OF INSANITY. 

I. Definitions and Descriptions ..... 262 

Definition of Insanity. — Illusion. — Hallucination. — Delusion. — Incoherence. 
— Delirium. — Lucid Interval. 

II. Classification . . . . - . 285 

III. Perceptional Insanities ..... 294 
a. Illusions. — b. Hallucinations. 

IV. Intellectual Insanities ...... 328 

a. Intellectual Monomania with Exaltation. — b. Intellectual Monomania 

with Depression. — c. Chronic Intellectual Mania. — d. Reasoning Mania. 
— e. Intellectual Subjective Morbid Impulses.—/. Intellectual Object- 
ive Morbid Impulses. 

V. Emotional Insanities ...... 400 

a. Emotional Monomania.— b. Emotional Morbid Impulses.— c. Simple 
Melancholia. — d. Melancholia with Delirium. — e. Melancholia with Stu- 
por.—/. Hypochondriacal Mania, or Melancholia. — g. Hysterical Mania. 
— h. Epidemic Insanity. 

VI. Volitional Insanities ...... 517 

a. Volitional Morbid Impulses.— b. Aboulomania (Paralysis of the Will). 

VII. Compound Insanities . . • • • 534 

a. Acute Mania. — b. Periodical Insanity.— c. Hebephrenia. — d. Circular 
Insanity.— e. Katatonia.— /. Primary Dementia.—^. Secondary De- 
mentia.— h. Senile Dementia.— i. General Paralysis. 



CONTENTS. x iii 

CHAP. PAGE 

VIII. Constitutional Insanities . . . . . 630 
a. Epileptic Insanity. — b. Puerperal Insanity. — c. Pellagrous Insanity. — 
d. Choreic Insanity. 

IX. The Causes of Insanity ..... 652 

X. The Prognosis of Insanity ..... 669 

XI. The Diagnosis of Insanity ..... 681 

XII. The Pathology and Morbid Anatomy of Insanity . . 691 

XIII. The Treatment of Insanity ..... V18 



TREATISE ON INSANITY, 



SECTION I. 

GENERAL PRINCIPLES OF THE PHYSIOLOGY 
AND PATHOLOGY OF THE MIND. 



CHAPTER I. 

NATURE AND SEAT OF THE MIND. 

The brain is the chief organ from which the force called 
the mind is evolved, and, so far as the present treatise is 
concerned, may be regarded as the only one. For, though, 
wherever there is gray nerve-tissne, whether it be in the brain, 
the spinal cord, or the sympathetic ganglia, nervous force is 
generated ; and, though all nervous force partakes more or less 
of the attributes of that which we call mind, its qualities, as 
exhibited by the force manifested by these latter two organs, 
are not of such a character, either in health or disease, as to 
come within the scope of the present treatise. It is with the 
mind developed by the brain that we have to concern ourselves. 

By mind, therefore, I understand a force produced by ner- 
vous action, and in man especially by the action of the brain. 
There are animals without brains, and others again with the 
cerebral mass so small as to be of much less importance than 
the spinal cord, and yet in all these there are continual mani- 
festations of the existence of mind. Indeed, in some of them 
the brain may be removed without, for a time, any considerable 
impairment of the mental force being produced. As we as- 
cend, however, in the scale of animal life, the brain becomes 
more and more predominant, until, when we reach the higher 
orders, at the head of which stands man, it is almost the exclu- 
sive seat of the mind. 



10 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

In former times the dependence of the mind upon the 
brain was not distinctly and fully recognized. The emotions, 
for instance, were supposed to have their seat in other organs 
—some in the heart, others in the liver, the spleen, and the 
bowels. So firmly was this idea implanted that it even at the 
present day influences our modes of speech. Thus we say of 
a man that he has a "good heart," or that his " heart is in 
the right place" ; the boy learns his lessons " by heart," the 
lover adores his mistress with his " whole heart," and the 
sinner, when he is converted from his evil ways, undergoes a 
" change of heart." The influence ascribed to the liver is 
shown in our words " melancholic " and " choleric," as applied 
to low-spirited and angry persons ; to the spleen in the term 
"splenetic," as indicating a spiteful individual; and we say 
of another that he has no "bowels of compassion." 

The connection between the mind and the brain is not 
doubted at the present day, although the character of the re- 
lation is still the subject of controversy. On the one hand, it 
is contended that the brain is only a tool or organ of which 
the mind makes use in man to manifest itself. According to 
this view, there is in every human being a mind not dependent 
upon the nervous system for its existence. On the other hand, 
it is asserted that the mind is directly the result of nervous 
action, and especially of the brain, and that if there were no 
nerve-substance there would be no mind. This view is that 
which is held by the majority of scientific writers of the pres- 
ent day. The discussion of the question need not, however, 
concern us here, for, whether the one or the other theory 
be correct, the brain and nervous system generally must be 
equally the subject of study in the consideration of either 
normal or abnormal mental manifestations. 

It may, however, be remarked that if the mind is in inde- 
pendent, self-conscious, immaterial personality, using the 
brain as its instrument for communicating with the external 
world, it is impossible for us to deny a like principle to the 
lower animals, differing only in degree as their brains differ 
from ours. They perceive, experience emotions, have intel- 
lects which memorize and exercise judgment, and wills to 
carry out, in accordance with their powers, the conclusions to 
which their reasoning leads them. 

According to the theological school of philosophers, the 
mind of an idiot is as good as the mind of Herbert Spencer — 



NATURE AND SEAT OF THE MIND. 11 

better, perhaps, in a moral point of view. The difference con- 
sists, in their opinion, solely in the fact that, whereas Herbert 
Spencer has a good tool to work with, the idiot has a bad one, 
and hence the product of his labor is of an inferior quality. 

The essential fault of these philosophers is that they con- 
found the mind with the soul. Science has nothing to do 
with the latter. Its existence is altogether a matter of faith 
— not of proof — which people believe in or not, according to 
the education they have received and the subsequent reflec- 
tion they have bestowed upon the subject. But the mind is 
found wherever there is gray nerve-matter in action, from 
the lowest invertebrate animal up to the highest and most 
intellectual man who walks the earth. With it science may 
properly concern itself, and with it theologians, as such, have 
nothing to do. 

The several categories of facts which go to establish the 
connection between the mind and the brain have been well set 
forth by Mr. Bain, 1 and are in general character similar to 
those which exist between any other viscus and the product 
of its action. They are as follows : 

1. The action of an organ, even within the limits of health, 
frequently gives rise to sensations of various kinds, and slight 
functional derangements are very distinctly felt. Thus the 
pain of indigestion is referred to the stomach or bowels, as the 
case may be ; disorders of the urinary excretion are mani- 
fested by uneasiness in the kidneys ; derangements of the 
secretion of the bile cause pain in the liver ; loud noises pro- 
duce unpleasant feelings in the ears ; and excessive or im- 
proper use of the eyes causes pain and other abnormalities 
of these organs. So it is with the brain, and often to a very 
marked degree. Though ordinarily we are not conscious by 
any particular sensation that we are using it when we think 
(and the same is true, mutatis mutandis, of the other organs 
mentioned), yet inordinate mental exertion, or continual dis- 
turbance, gives rise to headache, vertigo, and other derange- 
ments of sensibility referable to the brain. If the disturbing 
factor be continued in action, not only are these indications of 
disorder increased, but the mind shows evidences of derange- 
ment, and the organs of the body whose functions are con- 
trolled by the brain are likewise affected. As a consequence, 
insanity and paralysis result, and, upon post-mortem exami- 

1 "The Senses and the Intellect," second edition, London, 1864, p. 11. 



12 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

nation, the brain is found to be the seat of organic disease. 
There are many persons in whom only very slight mental 
action invariably produces pain in the head, and others again 
who are similarly affected by particular kinds of mental exer- 
tion, while other kinds, even in excess of proper limits, cause 
no sensations. Thus some individuals cannot attempt the 
solution of mathematical problems without suffering from 
pain in the head, and some experience a like disturbance from 
the very slight mental effort necessary in adding up a column 
of figures. 

2. Injury or disease of the brain impairs in some way or 
other the capacity or endurance of the mind. A blow on the 
head causes confusion of ideas, and, if hard enough, may abol- 
ish consciousness or the power of thought altogether. A piece 
of fractured bone, or a bullet pressing on the brain, likewise 
destroys the ability to think ; and the same result, or some 
other indication of mental disturbance, accompanies brain tu- 
mors, extravasations of blood within the cranial cavity, con- 
gestion, embolism or thrombosis of the cerebral blood-vessels, 
inflammation, or other disease of the brain. The fact that 
occasionally, on post-mortem examination, severe organic dis- 
ease of the brain is found to have existed during life without 
the production of notable symptoms, is no argument against 
the view here taken. All parts of the brain are not equally 
concerned in the production of mind, and by far the larger 
portion — the white substance — is only a medium for the trans- 
mission of the nerve-force which has been generated by the 
gray matter. I think, however, that it may be laid down as a 
law, admitting of no exception, that injury or disease of the 
convolutions, or any other portion of the gray tissue, is inva- 
riably accompanied by a disturbance of the functions of the 
brain of a character and extent commensurate with the seat 
and severity of the lesion. Cases are on record in which the 
consciousness of the individual has been suspended for sev- 
eral months, from the fact of pressure exerted by depressed 
bone upon some portion of the cortex, and in which, on the 
instant that the pressure was removed by surgical interference, 
consciousness was restored. 

3. The action of the brain, like that of any other of the 
animal organs, results in the disintegration of its substance, 
and this destruction is in direct proportion to the amount of 
mental work done. We find, therefore, that the alkaline 



NATUKE AND SEAT OF THE MIND. 13 

phosphates, which are mainly derived from the destructive 
metamorphosis of the nervous tissue, and which are excreted 
by the kidneys, are increased in quantity after severe intel- 
lectual labor, and are diminished by mental quietude. In a 
memoir published several years ago, I gave the results of a 
series of experiments performed upon myself, which show 
conclusively that increased use of the brain causes increased 
decay of its tissue, as demonstrated by the largely augmented 
quantity of phosphates excreted by the urine. 1 As the chem- 
ist, by weighing the ashes on the hearth, determines how 
much wood has been burnt, so the physiologist, by weigh- 
ing the ashes of the brain — the phosphates — measures the 
amount of thought which has resulted from the combustion 
of the encephalon. 

4. The size of the brain is well known to bear a direct rela- 
tion to the intelligence of the individual ; and, when all other 
conditions are alike, it may be said that the largest brain will 
produce the greatest amount of mental energy. This deduc- 
tion is based upon the fact that, as a rule, the larger the brain 
as a whole, the greater is the quantity of gray matter upon 
which its activity depends. Occasionally there are apparent 
exceptions to this statement, but there is reason for thinking 
that they are not so real as they seem. It is entirely conso- 
nant with the results of experience to meet with individuals 
of moderate-sized brains and great intellectual activity in 
whom the cortical substance is of unusual thickness, and the 
convolutions of more than ordinary complexity. 

At the same time it is a well-known fact that, when the 
brain is markedly below the average in weight, mental weak- 
ness is a necessary concomitant. Thus Dr. Thurnam 3 has 
shown that the average weight of the brain of Europeans is 
49 ounces, while in ten men remarkable for their intellectual 
development it was 54*7 ounces. Of these, the brain of Cuvier, 
the celebrated naturalist, weighed 64*5 ounces, Spurzheim's 
55'6, and Daniel Webster's 53*5. On the other hand, the brain 
is small in idiots. In three individuals of very feeble intelli- 
gence, whose ages were sixteen, forty, and fifty years, respect- 
ively, Tiedemann found the weights of their brains to be 19} , 

1 " Urological Contributions," American Journal of the Medical Sciences, 
April, 1856, p. 330; also, "Physiological Memoirs," Philadelphia, 1863, p. 
17. 

3 Journal of Mental Science, April, 1866. 



14 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

25f , and 22£ ounces. Mr. Gore ' has reported the case of a 
woman, forty- two years of age, whose intellect was infantine, 
who could scarcely say a few words, whose gait was unsteady, 
and whose chief occupation was carrying and nursing a doll. 
After death, the weight of her brain was found to be but 10 
ounces and 5 grains. 

Mr. Marshall 3 has also reported a case of microcephaly 
existing in the person of a boy twelve years of age, whose 
brain weighed but 8£ ounces. The convolutions were strongly 
marked, though few in number and narrow. In a remarkable 
case which came under my own observation, the individual, 
a woman twenty-two years of age, was unable to talk, though 
she could utter a few inarticulate sounds expressive of the 
more imperious of her wants. The cranium had a circumfer- 
ence of only 14 inches at its largest measurement, and the 
brain was found to weigh but 23J ounces. The thickness of 
the gray matter at no part of the surface exceeded -fa of an 
inch, and generally was below this point, whereas in the brain 
of a person of ordinary intelligence it is often more than 
twice this depth. The convolutions were of very simple 
structure, and the fissuration comparatively slightly marked. 
In no adult not an idiot is the cranium less than 17 inches in 
circumference. 

Gratiolet 3 fixes the lowest weight of the human brain in a 
person of ordinary intelligence at about 31f ounces. When 
the weight is below this, the individual is necessarily an idiot. 

Thurnam 4 states that, as the result of his observations, the 
weight of the female brain is about ten per cent, less than that 
of the male, and this is about the difference as determined by 
other observers. Of course this is an average result, for there 
are many women with larger brains than many men, and of 
consequently higher mental capacity. 

5. Experiments performed upon the nerves and nerve-cen- 
tres show that from the brain proceeds the force by which 
muscles are moved ; that it is the chief organ by which sensa- 
tions are perceived — all the special senses, with the possible 

1 " Notes of a Case of Microcephaly," Anthropological Bevieic, No. 1, May, 
1863, p. 168. 

2 "Brain and Calvariura of a Microcephale, Anthropological Review, No. 
2, August, 1863, p. 8. 

3 " Anatomie comparee du systeme nerveux," Paris, 1857, t. ii, p. 318. 

4 Op. cit. 



DIVISIONS OF MIND. 15 

exception of touch, having their centres of perception in the 
brain alone — and that certain portions of the brain are in di- 
rect relation with certain faculties of the mind, sensorial oper- 
ations and muscular actions. Thus, division of a nerve sup- 
plying any particular muscle cuts off the connection between 
the brain and that muscle, and hence the will can no longer 
act upon it. Division of any nerve of special sense prevents 
the perception of sensorial impressions. If, for instance, the 
optic nerve be cut, though the whole optical apparatus of the 
eye remain unimpaired, the sight is destroyed, for the reason 
that the communication with the organ of perception is sev- 
ered. Again, by destroying certain portions of the brain, the 
power to exercise those sensorial organs which are under the 
control of the injured regions is lost, faculties of the mind are 
abolished or impaired, and the ability to move the muscles 
which derive their innervation from those parts is abolished 
or diminished. From all of which considerations the connec- 
tion between the brain and the mind is as clearly made out 
as any other fact in physiology. 1 



CHAPTER II. 

DIVISIONS OF MIND. 

The mind, like some other forces, is compound — that is, 
is made up of several sub-forces. These are : perception, in- 
tellect, emotions, and will. All the mental manifestations of 
which the brain is capable are embraced in one or more of 
these parts. Either one may be exercised independently of 
the other, though they are very intimately connected, and in 
all continuous mental processes are brought more or less into 
relative and consecutive action. To the consideration of some 
of the primary facts associated with each of these divisions a 
brief space may be given. 

1. Perception. — By perception is to be understood that part 

1 That the spinal cord is likewise the seat of certain elements of mind, or 
rather is capable of evolving them, can be satisfactorily shown by a parity of 
reasoning. For the illustrations and arguments relative to this subject, the 
reader is referred to the author's inaugural address as President of the New York 
Neurological Society, entitled " The Brain not the Sole Organ of the Mind," Jour- 
nal of Nervous and Mental Disease, January, 1876. 



16 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

of the mind whose office it is to place the individual in rela- 
tion with external objects. For the evolution of this force 
the brain is in intimate relation with certain organs which 
serve the purpose of receiving the impressions of objects ac- 
cording to their several kinds. These are the organs of the 
special senses. In order that there may be a perception, there 
must, therefore, be a special apparatus of an optical, acoustic, 
olfactory, gustatory, or tactile character, a nerve to transmit 
to the brain the peculiar impressions made upon the organ, 
and a ganglionic centre to convert the impression into a per- 
ception. The eye, for instance, would be just as capable of 
receiving images upon the retina if the optic nerve were 
divided, but the brain would obtain no knowledge of them, 
and there would, consequently, be no perception. And 
though the eye and the optic nerve should both be in a nor- 
mal condition, if the ganglion in connection therewith should 
be sufficiently diseased, either there would be a perverted 
perception or none at all. Like reasoning is, of course, ap- 
plicable to each of the other special senses — hearing, smell, 
taste, and touch. 

But, although no knowledge of external objects can be ob- 
tained without the intervention of the special senses, there 
may be in certain diseased or disordered states of the brain 
false perceptions which are altogether of esoteric formation. 
These are called hallucinations, and will engage our attention 
farther on. For their creation no sense-organ is requisite ; 
indeed, they are quite common in persons who have lost their 
eyesight or hearing, and who, nevertheless, have frequent 
hallucinations of either sense. But no hallucination of a 
sense can exist unless the individual has, at least at some 
former period, exercised the sense in question. 

Perception may exist without there being at the time any 
superior intellectual act — without any ideation whatever. 
Thus, if the cerebrum of a pigeon be removed, the animal is 
still capable of seeing, of hearing, and of exercising the other 
senses, but it obtains no idea from the impressions which 
have been made upon the perceptive ganglia. If a candle be 
moved in front of the eyes, the head is turned in accordance 
with the motion of the candle, but no alarm is excited, and 
there is no attempt to escape. If the hand be stretched out 
as if to seize the bird, it is equally quiet, although previously 
to the removal of the hemispheres it may have been particu- 



DIVISIONS OF MIND. 17 

larly wild and timid. The discharge of a pistol near its head 
causes the animal to open its eyes, showing that the sound is 
heard, but it derives no idea from what would in its normal 
condition excite the emotion of fear and develop complex 
muscular actions in its endeavors to get away. If the foot be 
pinched, an effort is at once made to withdraw the member, 
and this is repeated as often as the excitation is applied, the 
animal in the mean time remaining otherwise undisturbed. 
It is evident, therefore, that no idea is obtained from the im- 
pressions which are made on the special sense-organs, and 
that the memory of them does not exist for a single instant. 
The mind, with the exception of perception, has been removed 
with the hemispheres. 

In certain abnormal, or quasi abnormal, conditions of the 
system, the several categories of mental faculties, with the ex- 
ception of perception, appear to be in a state of suspension. 
Thus, in somnambulism and trance, whether idiopathic or 
artificially induced, the perceptions often reach a very high 
degree of acuteness, while the intellect, the emotions, and 
the will are in abeyance. In the insane a like condition some- 
times exists. 

Perception is the starting-point of all ideation. An indi- 
vidual born without any of the special senses, or without the 
essential nervous structures for developing sensorial impres- 
sions into perceptions, would be unable to form the simplest 
possible idea of any object or subject. The avenues of knowl- 
edge in such a person would be closed, and — no matter how 
perfect the rest of the nervous system might be, no matter 
how complex the cerebral convolutions, or how thick the gray 
matter of the cortex — there would be no mind. The brain can 
originate nothing ; ideas are not innate ; they are derived 
entirely from without. The brain takes the impressions it re- 
ceives, converts them into the appropriate perceptions, elabo- 
rates these into thousands of varied ideas, develops these 
primary ideas into thousands of others, and so on, without 
end ; but the beginning is in every case material. The sparks 
that light up the intellectual, emotional, and volitional fires, 
come from the things around us ; and though the mind of 
a Socrates might potentially exist in the cerebral cortex of 
a man without sight, hearing, touch, taste, or smell, it would 
never kindle into the faintest scintillation, though it endured 
for an eternity. Such a man would be unable to conceive the 

2 



IS PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

idea that one and one make two ; he conld never even know 
the fact that there is such a number as one, as distinct from 
two. There is no way by which it could be taught to him. 

There are reasons for believing that all perceptions are 
formed in the optic thalami. Magendie l was the first who 
pointed out their relations to sensibility. He ascertained that 
their irritation in animals caused excessive pain, while the 
other parts of the brain might be wounded without producing 
evidences of suffering. 

They have also been regarded as specially the centres for 
vision. Although Todd, Carpenter, and others have considered 
the optic thalami as centres for sensorial impressions, Luys, a 
more than any other physiologist, has developed this idea, 
and has adduced arguments in its support which it is difficult 
to overlook. His doctrine is that the optic thalami are reser- 
voirs for all sensorial impressions coming from the periphery 
of the nervous system, that with other ganglionic masses they 
elaborate these impressions, and that by means of the fibres 
of the corona radiata they transmit them to the cortex to be 
still further perfectionated by being converted into ideas. In 
his own language: "All sensorial impressions, after having 
been received and concentrated in the gray substance of the 
optic thalami, are irradiated toward the different regions of 
the cortical periphery. The white central fibres transmit 
them, and the gray substance of the convolutions receives and 
elaborates them. ' ' 3 

Experimental physiology tends to establish this doctrine ; 
and, though the position of the optic thalami is such as to 
make it a matter of difficulty to act upon them with the same 
degree of facility as upon the cortex, the obstacle has been, 
in a great measure, overcome by Fournie, 4 and we are thus 
placed in possession of data which have a distinct connection 
with the point at issue. 

Fournie's method consisted in injecting, by means of a 
hypodermic syringe, caustic solutions — such as a strong solu- 
tion of chloride of zinc — into the brain, observing the result- 
ing phenomena, and then, after death, carefully noting the 
part of the organ in which the injection had been deposited. 

1 " Lemons sur le systeme nerveux," t. i, p. 103, et seq. 

3 "Pvecherches sur le systeme nerveux," Paris, 1865, p. 198, et seq. 

3 Op. cit., p. 346. 

4 " Sur le fonctionnement du cerveau." Paris, 1873. 



DIVISIONS OF MIND. 19 

Several of his experiments related to the optic thalami, 
and, without referring to the other results, it may be stated 
that in every one there was a more or less complete loss of 
sensation. In one of his cases the needle traversed the cornu 
ammonis, and the injection was thrown into the centre of the 
optic thalamus of the left side. As a consequence, there was 
complete abolition of all sensibility. 

As we shall see farther on, there are many facts in morbid 
anatomy which go to support this view of the relation be- 
tween the several sensorial organs and the optic thalami. 

The accompanying diagram (Fig. 1) exhibits the connec- 

Fio. 1. 





a, organ of sense (eye) ; b, connecting nerve for transmission of impressions ; c, ganglion 
for conversion of impressions into perceptions. 

tion of an organ of a special sense, as, for instance, the eye, 
with its perceptive ganglion. 

Besides the generally recognized five special senses — sight, 
hearing, taste, smell, and touch — there is another, which is 
known as the muscular sense, the existence of which seems to 
be well established. By this sense we are enabled to deter- 
mine, without the assistance of the other senses, the weights of 
bodies and the exact state of contraction of any particular 
muscle under the control of the will. It is, probably, also 
through this sense that the muscular movements are co-or- 
dinated and the requisite degree of contraction initiated and 
maintained. 

But there are others which, though not senses in the strict 
signification of the word, are, at any rate, sensations, and 
capable of giving rise to perceptions. They are probably 
modifications of the sense of touch. They arise through the 
operations of the various organs of the body, and are inti- 
mately associated with imperative needs of the body in its 
struggle for existence. 

These are : hunger, the feeling which, starting in the stom- 
ach, indicates the necessity for food ; thirst, which experienced 
in the fauces and throat informs us that the organism requires 



20 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

water ; the respiratory sense, which, when allowed to act to 
its extreme degree, causes a feeling of suffocation, and which, 
originating in the lungs, informs us that a due amount of pure 
air is not being inspired ; and the reproductive or genesic 
sense, which is intimately concerned with the preservation of 
the species, but which primarily relates to sexual intercourse 
and the pleasurable feeling resulting from venereal excite- 
ment. The sensation experienced in the bladder when the 
contained urine is increased beyond a certain quantity, and 
that felt in the rectum when it is distended with faeces, are 
still more analogous with touch as it exists in the skin. The 
pains felt in the different organs and structures of the body 
when they are the subjects of disease or derangement are also 
to be embraced under the same category. 

All the perceptions are subject to aberrations, either from 
disorder of the organ which receives them as impressions, the 
nerve or nerves which transmit the impressions to the brain, 
or of this latter structure itself. With the first two series of 
derangements we need not, in the consideration of mental de- 
rangement, concern ourselves ; the third will be fully brought 
under notice in a subsequent part of this treatise. 

2. The Intellect. — In the normal condition of the brain, the 
excitation of a sense, and the consequent perception, do not 
stop at the special ganglion of that sense, but are transmitted 
to a more complex part of the brain, where the perception is 
resolved into an idea. Thus, the image impressed upon the 
retina, the perception of which has been formed by a sensory 
ganglion, ultimately causes the evolution of another force by 
which all its attributes capable of being represented upon 
the retina are more or less perfectly appreciated, according to 
the structural qualities of the ideational centre. To the for- 
mation of the idea several important faculties and modes of 
expression of the intellect contribute. 

Thus, if, to employ the example already used, the retina 
has received the image of a ball, a ganglion converts this 
into a perception, and a higher one into an idea, and this idea 
relates to the size, the form, the color, the material, etc., pri- 
marily ; and the origin, ownership, uses, etc., secondarily. In 
gaining this conception of the thing, the image of which has 
been impressed upon the retina, the various faculties of the 
intellect are brought into action, and the process of think- 
ing is carried on. These faculties, or functions, as generally 



DIVISIONS OF MIND. 21 



recognized by metaphysicians, are five in number — memory, 
judgment, abstraction, reason, and imagination. Bain 1 re- 
duces them to three — consciousness of difference, conscious- 
ness of agreement, and retentiveness. From a purely philo- 
sophical point of view, his classification is more correct than 
the older one, but, for the purposes of the present inquiry, the 
latter is to be preferred as being more generally understood, 
and more in relation with derangements of the intellect. 

The region of the brain which is directly concerned with 
the elaboration of ideas is the cortex. Impressions from the 
perceptional and emotional centres are transmitted to the gan- 
glionic matter forming the periphery of the brain, and are 
there converted into ideas. Moreover, it is doubtless this por- 
tion in which ideas are stored up for future use, and from 
which they are brought out when required. The accompany- 
ing diagram (Fig. 2) shows the relation which exists. 

Fig. 2. 





a, the organ of sense ; S, the nerve for transmission to c, organ of perception ; d, the white 
fibres of the brain transmitting the perception to <?, the cortex, where it is converted 
into an idea. 

Any one or all of the faculties of the intellect, as above 
enumerated, may be disordered in insanity. 

3. The Emotions. — An idea, in its turn, excites another part 
of the brain to action, and an emotion is produced ; or this 
last-named force may be evolved under certain circumstances 
without the intermediation of the idea, but solely from the 
transmission of a perception to the emotional ganglion. 

1 "The Senses and the Intellect," third edition, New York, 1872, p. 321, 
et 8eq. 



22 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

An emotion is that pleasurable or painful feeling which 
arises in ns in consequence of sensorial impressions or intel- 
lectual action. According to Bain, the word emotion is used 
to comprehend all that is understood by feeling, pleasure, 
pain, passion, sentiment, affection, etc. 

The emotions which are principally the subjects of de- 
rangement in cases of insanity are anxiety, anger, fear, love, 
egotism, vanity, ambition, j ealous y, avarice, superstition, fa- 
naticism, and religious feeling. 

Within the limits of health the emotions act powerfully 
on certain organs of the body, and thus express their own 
activity. Thus, grief is exhibited by the flow of tears ; ex- 
treme joy may also cause weeping. The jaw falls, and the 
angles of the mouth curve downward, in mortification or sor- 
row, while in pleasure the face expands laterally. The eyes, 
the nose, and the mouth are the facial centres from which 
emotional expression is mainly produced. Other organs, as 
the salivary glands, the heart, the mammary glands, the liver, 
the kidneys, and, in fact, nearly every viscus of the body, 
may exhibit the effect of emotions by the transmission of 
excitations through the sympathetic nerve. Most of the re- 
sulting effects are due to the fact that the sympathetic system 
especially presides over the vaso-motor nerves, and thus regu- 
lates the calibre of the blood-vessels. 

Certain animal appetites, as the desire for alcoholic liquors, 
for opium, chloral, etc., for the pleasures of the table, for 
gambling, for sexual intercourse and its aberrations, are some- 
times regarded as emotions, but it appears to me without good 
reason. Appetites such as those cited may, and often do, con- 
stitute the basis for emotions ; they are the starting-point 
from which emotions spring, but they are entirely different, as 
they rest upon a lower plane. 

The causes of the development of this or that emotion are 
also to be found in age, sex, climate, temperament, heredity, 
certain diseases, puberty, menstruation, pregnancy, the 
civil state as regards marriage or celibacy, and many other 
factors. 

The ancients localized the emotions in the heart and other 
viscera ; and even Cabanis and Bichat, considering the dis- 
turbances which take place in the thoracic and abdominal or- 
gans in connection with emotional excitement, mistook the 
effect for the cause, and localized the emotions in the liver, 



DIVISIONS OF MIND. 23 

the lungs, the intestines, and especially in the heart. It is 
well known that certain depressing feelings give rise to a 
painfnl sensation in the hypochondriac regions, and that this 
fact is actually the origin of the name of a peculiar species of 
melancholy. Anxiety produces a similar effect in the epigas- 
trium. 

Descartes, Gall, Broussais, Brachet, and others, place them 
in the brain, and this view is the one now generally held by 
physiological psychologists. It is true that the emotions are 
often manifested in the organs referred to, through the inti- 
mate relations which they have with the brain by the sympa- 
thetic and pneumogastric nerves ; but they might, with as 
much logical force, be located in the muscles of the face, by 
reason of the fact that certain of them contract under the in- 
fluence of joy or grief, or in the lachrymal gland because sor- 
row causes the tears to flow. The influence of this hypothesis 
is, however, still widely shown by its effects upon our every- 
day speech. "We say a person has a "good or a bad heart," 
that "her heart was broken," or that a coward is " white-liv- 
ered," and so on. There is, however, no anatomical, physio- 
logical, or pathological evidence going to show that the emo- 
tions have any other connection with the sympathetic sys- 
tem than the fact that it is through that system that they are 
chiefly manifested. 

On the contrary, there is every reason to believe that the 
emotions, like perception and the intellect, are seated in the 
brain. Ferrier 1 expresses the opinion that the sensory, idea- 
tional, and emotional centres are one and the same, but of 
this there is no satisfactory proof. The most that can be said 
is that they are localized in the brain, and probably in the 
cortex, in cells contiguous to those concerned in the elabora- 
tion of ideas. Farther on he still more definitely places them 
in the occipital lobes, but this view cannot yet be accepted. 

We cannot gain much in investigating the questions con- 
nected with the seat of the emotions from experiments on the 
lower animals. The mammalia do not bear the necessary 
operations, and birds, reptiles, and fish are not possessed of 
sufficient emotional development to make experiments on 
them of any value. But disease makes experiments for us, 
and we learn, from the study of the various disorders and 
lesions to which the brain is subject, that there is scarcely one 

1 " The Functions of the Brain," London, 1876, p. 260. 



2± PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

that does not produce at some time or other of its career a 
change in the emotional characteristics of the affected indi- 
vidual. Thus, for instance, cerebral haemorrhages and em- 
bolisms are almost invariably accompanied or followed by 
marked emotional derangement, and often to the extent of 
completely reversing the normal tendencies of the patient. 
Referring to this subject in relation to cerebral haemorrhage, 
I have said : ' u The mental characteristics of the patient will 
be found to have undergone a radical change. He is irri- 
table, unreasonable, and fretful. His sense of the proprieties 
of life, which may in health have been very delicate, becomes 
obtuse, his memory is notably impaired, and his reasoning 
powers greatly diminished. The greatest change, however, is 
perceived in the emotional faculties. He laughs at the veriest 
trifles, and sheds tears profusely at the least circumstance cal- 
culated to annoy him. Even for years after, this peculiarity 
is noticed." And, again : a 

"Even after years his emotions are abnormally excitable. 
A patient now in the New York State Hospital for Diseases 
of the Nervous System informs me that he sheds tears every 
time a funeral passes him, and that even hearing of any one's 
death, or reading the obituary column in a newspaper, causes 
his feelings to get the better of him. In the lightest forms 
of the attack this easily aroused emotional disturbance is a 
marked feature for years subsequently, if it ever entirely dis- 
appears." 

In the case of a gentleman, the subject of a very slight 
cerebral haemorrhage, which left scarcely any paralysis after 
it, and which the clinical features showed was situated in one 
of the ganglia of the left corpus striatum, the grief excited by 
the fact that his coffee was cold caused him to shed tears like 
a child. This gentleman was normally of great strength of 
character, and not given to exhibit his feelings. At the time, 
he held one of the highest offices in the Government of the 
United States. 

A person of my acquaintance had his whole character 
changed by a slight attack of cerebral congestion. Naturally 
he was of good disposition, amiable in his character, and con- 
siderate in his dealings with others ; but after a vertiginous 
seizure, attended with unconsciousness of but a few moments' 

1 " A Treatise on the Diseases of the Nervous System," seventh edition, 
New York, 1881, p. 88. 3 Op. cit., pp. 92, 93. 



DIVISIONS OF MIND. 25 

duration, his whole mental organization underwent a radical 
change ; he became deceitful, morose, and exceedingly over- 
bearing and tyrannical toward all with whom he came in con- 
tact and whom it was safe for him to maltreat. His likes and 
dislikes were entirely reversed in many important instances. 

Bucknill 1 and Tuke refer to the case of a lady whose 
character had always been distinguished for conscientious- 
ness, whose religious education had been of a sombre kind, 
and who, suffering from an attack of small-pox, attended 
with congestion of the brain, recovered with the natural bent 
of her disposition greatly exaggerated. The irritability of 
conscience had become an actual disease, destroying her hap- 
piness and rendering her incompetent to discharge any of the 
duties of life. 

Intense or long-continued emotional disturbance is among 
the chief factors in the causation of insanity, as will be fully 
shown in a subsequent part of this treatise. 

McCosh 2 asserts that to the production of an emotion 
" there is need first of some understanding or apprehension " — 
that is, of an idea ; but I think this is not altogether correct, 
for it would seem from experience that a simple perception 
without understanding or apprehension may give rise to 
marked emotional manifestations. Thus, the feeling of un- 
easiness in the stomach consequent upon an undigested meal 
may produce the most profound melancholy ; certain indefin- 
able sensations in the generative organs, scarcely perceived, 
may cause the development of the emotion of love in its most 
intense form ; a gouty pain in the great toe may prompt to 
the most immeasurable anger. Indeed, emotions may be de- 
veloped as the direct consequences of disturbances in the 
viscera, unaccompanied by any sensation whatever, as, for 
instance, the mental depression, with its accompanying emo- 
tional disturbances due to painless liver disorders, and like 
states developed by morbid conditions of the blood circulat- 
ing in the brain. In none of these instances is there neces- 
sarily the faintest understanding or apprehension. And, as 
regards the special senses, the fact, that active emotions may 
be excited through the perceptions they induce without the 
intervention of the intellect, must, I think, be recognized by 
all inquirers, although the feeling evolved may not be so 

1 " A Manual of Psychological Medicine," etc., London, 1858, p. 375. 

2 " The Emotions," New York, 1880, p. 1. 



26 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

strong as when ideation is also brought in as a factor. The 
sight of a person undergoing bodily pain excites in us a feel- 
ing of compassion, provided the sufferer indulges in tears and 
lamentations, and writhes, let us suppose, under the knife of 
the surgeon. If, on the contrary, he restrains the manifesta- 
tions of the pain he is enduring, we look beyond his present 
condition and contemplate the benefit he is probably to receive 
from the operation, and the pity we would have felt in the 
first instance is scarcely, if at all, experienced. Among the 
insane, the excitation of emotions from illusions and hallu- 
cinations, which, as we have seen, are only false perceptions, 
is common enough. 

Many persons are more governed by their emotions than 
by their intellects in their beliefs and actions. They accept 
an article of faith because they hear it enunciated amid the 
surroundings of groined ceilings, stained glass, a dim light, 
solemn music, and a gorgeous ceremonial, without stopping 
to submit it to calm investigation when the circumstances are 
such that the intellect can have full play. Moved by the 
pity excited at the sight of a weeping wife and children pur- 
posely brought into the court-room to influence their judg- 
ment, they, as jurymen, acquit a man whom the evidence has 
clearly shown to be guilty of an atrocious crime. In the one 
case, the belief will probably be of short duration ; in the 
other, a great wrong is done to society by turning loose upon 
it a person who will probably do it further injury, and in 
depriving it of the advantage of example to other would-be 
offenders against the law. At the same time, the emotions 
should be allowed their legitimate power in governing our 
actions, and we can often trust to them as safe guides. With 
matters of faith or belief, however, they should have nothing 
to do. 

The mechanism of the development of emotions from per- 
ceptions and ideas is shown in the accompanying diagram 
(Fig. 3), in which a is the organ of sense ; 5, the nerve of trans- 
mission ; c 9 the perceptive ganglion ; d, the fibres of transmis- 
sion to e 9 the ideational ganglion ;/, the fibres of transmission 
to g, the emotional ganglion ; and h, fibres of communication 
between e, the ideational, and g, the emotional ganglia. An 
emotion, therefore, may be excited in g by a perception com- 
ing directly from c, through the fibres/, or indirectly through 
the fibres d to e, where it is converted into an idea and trans- 



DIVISIONS OF MIND. 



27 



mitted to g through the fibres h; or it may be developed from 
an idea starting from e and reaching g through the fibres 7i. 



Fig. 3. 




4. The Will is that mental force by which the emotions, the 
thoughts, and the actions are controlled. The product of the 
force is called a volition. 

The influence of the will is greatest in the reverse order in 
which its subjects are mentioned in the preceding paragraph ; 
that is, it is most powerful over the muscular system of the 
body, next over the thoughts, the current of which is often 
regulated and directed by the will, and least of all over the 
emotions. When we hear of people controlling their feelings, 
it is not, generally, in reality the feelings which are held in 
subjection, but merely the manifestation of them. A man, 
therefore, who possesses the power of preserving his equa- 
nimity in the presence of circumstances calculated to rouse 
the emotions to the highest pitch, is able to abstain from tears 
or laughter, or the ordinary indications of fear or anger, while 
the emotion calculated to excite either is experienced to its 
utmost degree. 

A story is told of two officers who were serving together in 
the Peninsular War, which illustrates this volitional control 
of the manifestations of a powerful emotion. One of them, 
whom I will call Captain Smith, was remarkable for his bull- 
dog bravery, which never failed him, under any circumstances, 
when mere animal courage was required. The other, Captain 
Jones, was a good officer, but was thought by some to be de- 
ficient in the contempt of danger, which is, after all, the least 



28 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

qualification of a soldier. The bullets were whistling around, 
when Captain Smith, riding up to Captain Jones, who stood 
pale, but collected, at his post, said, with the inexcusable 
brusquerie to be expected of such a person : 

" Captain Jones, you look as if you were frightened ! " 

" Yes," replied Jones, " I am frightened, and if you were 
half so much frightened as I am you would run away." 

Still, it is not to be doubted that, to a certain extent, the 
emotions are under the control of the will. A man may 
strengthen his emotions, lessen them, subdue them absolutely, 
or create those which are not natural to him, by the simple 
force of his will acting in accordance with his desires. The 
medical student, whose horror at the sight of blood causes 
him to faint, by lessening the action of his heart, when he 
sees his first surgical operation, in a short time overcomes his 
repugnance, and, after a while, becomes a fearless surgeon. 
The soldier who in his first battle is so terrified that his urine 
and faeces escape from him involuntarily, perseveres till he is 
renowned for his gallantry and daring under the most tremen- 
dous fire. 

The influence of the will is markedly exhibited in the 
power to recall or reproduce ideas which have been experi- 
enced at some former time. This power may exist when that 
of fixing the attention upon subjects is notably diminished. 
Thus, a person suffers from an attack of cerebral haemorrhage 
or other brain disease which lessens the force of the mind. 
In such a case it often happens that the ability to recall im- 
pressions made many years previously remains undiminished, 
while he finds it impossible to recollect events which occurred 
only an hour or two ago. He remembers, with unimpaired 
vividness, unimportant incidents of his youth, and yet has 
forgotten the name of the hotel at which he is stopping, or 
whether or not he ate fish for his dinner. In the latter cir- 
cumstances no effort of the will is competent to recall the 
facts, because he has lost the power of concentrating the atten- 
tion. No impression has been formed, and no idea has been 
evolved. 

For the exercise of volition, consciousness is necessary. 
We are constantly performing acts of which we have at the 
time no knowledge ; but they are automatic, not voluntary. 
We will, for example, to go to a friend's house, and we per- 
form the necessary volitional acts initiatory of the proceeding ; 



DIVISIONS OF MIND. 29 

but we do not keep on willing each individual step that we 
take on our way, and we arrive at the consciousness that we 
have reached his door, while the will during the journey has 
either been dormant, or, perhaps, engaged in directing a con- 
versation with a person who has joined us. Such acts are 
performed by the force evolved from ganglia lower in function 
than those which produce the will, which simply sets them 
in operation, and stops them when desirous so to do. Volition 
is, therefore, an instantaneous and transitory process. Strong 
determination causes, however, repeated volitional acts of 
like character. Beattie x is, therefore, wrong when he says : 
" Some acts of the will are transient, others more lasting. 
When I will to stretch out my hand and snuff the candle, the 
energy of the will is at an end as soon as the action is over. 
When I will to read a book or write a letter from beginning 
to end without stopping, the will is exerted till the reading or 
the writing be finished. We may will to persist for a course 
of years in a certain conduct ; to read, for example, so much 
Greek every day till we learn to read it with ease ; this sort of 
will is commonly called a resolution." 

It requires no profound consideration to perceive the many 
errors contained in this brief quotation. A resolution to 
study Greek for a number of years would require thousands 
of distinct volitional acts for its realization. The idea that 
while studying each daily lesson the will would be actively 
engaged in willing the performance of the task is one which 
our experience emphatically contradicts. After we are con- 
scious of a volition to do a particular thing, the will has noth- 
ing further to do with the act. 

The will has often been confounded with desire. Thus 
Hartley ' says : 

" The will appears to be nothing but a desire or aversion 
sufficiently strong to produce an action that is not automatic, 
primarily or secondarily. At least, it appears to me that the 
substitution of these words for the word will may be justi- 
fied by the common usage of language. The will is, there- 
fore, that desire or aversion which is strongest for the present 
time." 

Mr. James Mill 3 apparently holds a like view when he says : 

1 " Elements of Moral Science," vol. i, Edinburgh, 1790, p. 217. 

2 " Observations on Man," etc., 1791, p. 219. 

3 "Analysis of the Human Mind," 1830, p. 279. 



30 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

"I believe that no case of voluntary action can be men- 
tioned in which it would not be an appropriate expression to 
call the action desired." 

Many other metaphysicians hold a like doctrine — a doc- 
trine which, as Mansel ' asserts, was overthrown as one of the 
earliest results of psychological analysis, and which is con- 
trary to the consciousness of every persgn who has experi- 
enced them both, " however much they may have been con- 
founded by the perversity of a few unscrupulous system- 
makers." Desire and will may, indeed, be the direct oppo- 
nents of each other. A man may desire his neighbor's watch, 
but will be very far from making a volitional effort to take it 
out of his pocket. He often wills in opposition to his desires, 
and desires in opposition to his will. 

Cases in illustration of these points often occur to the 
physician, although, perhaps, not familiar to the metaphysi- 
cian. Two instances of the kind are cited by Dr. J. H. Ben- 
net, 2 to whom they were furnished by Sir Robert Christison. 
In one of them, a gentleman was often unable to do very sim- 
ple acts which he wished to perform, although his will-power 
was exerted to its utmost. For instance, in undressing for 
the night he would be two hours before he could take off his 
coat, all his mental faculties except the will being perfect. 
On one occasion, having ordered a glass of water, he was un- 
able to take it off the tray, though desirous of so doing, and 
the servant was kept standing a half -hour before success at- 
tended his efforts. In the other case, if the subject, when 
walking in the street, came to a break in the line of houses, 
his will suddenly became inoperative, and he could not, in 
spite of all his power of volition, proceed another step. An 
unbuilt-on space in the street was sure to stop him. Crossing 
a street was also difficult, and on going in or out of a door his 
movement was always arrested for some minutes. 

A similar case has recently come under my own notice. A 
gentleman from Massachusetts consulted me for what he des- 
ignated "a paralysis of the will," which was chiefly mani- 
fested in undressing himself at night and dressing himself in 
the morning. It was impossible for him to take off his clothes 
or to put them on in accordance with the order he wished. 

1 " Metaphysics; or, The Philosophy of Consciousness, Phenomenal or Real," 
Edinburgh, 1860, p. 171; also, " Encyclopaedia Britannica." 

2 " The Mesmeric Mania of 1851," p. 16. 



DIVISIONS OF MIND. 31 

He would begin, for instance, by endeavoring to remove his 
shoes, but, after vainly trying to bring his will in subjection 
to his desire, would desist and turn his attention to the task 
of taking off his coat, with no better success. After an hour 
or two spent in this way, to no purpose, he would succeed, 
generally, in getting his clothes off, but quite often he was 
obliged to summon assistance. In the morning a similar ex- 
perience was certain to occur. Frequently, as he told me, he 
would sit for half an hour with his stockings in his hands, 
unable to determine which one to put on first. 

Legrand du Saulle 1 has very thoroughly described such 
cases under the name of " Folie du doute," and they will sub- 
sequently engage our attention more fully. 

In certain of the neuroses, notably in hysteria and insan- 
ity, this inability to exert the power of the will is a prominent 
feature. In the latter condition the will is often exercised 
against the desires and the whole system of thought of the 
individual, producing what is known as " morbid impulse." 
In these cases, the will, as it were, breaks loose from the intel- 
lect and causes the perpetration of acts of immorality or vio- 
lence. Even within the limits of mental health some persons 
are noted for the strength of the will, and others for its feeble- 
ness. 

The influence of certain narcotics and stimulants in weak- 
ening the power of the will is a well-known fact. Among 
them, opium and alcohol are especially to be noted. The for- 
mer, in most cases, produces its effect upon the will of the 
individual without in the slightest degree impairing the intel- 
lect. The latter, however, seems to have a more complex 
action, for it not only diminishes the will-power and places its 
subject under the control of others, but it prompts to the per- 
petration of acts of violence, the tendency to which the indi- 
vidual is unable to resist. 

The will is also suspended in reverie, in somnambulism, 
and in the induced condition known as hypnotism. In this 
last-named state the subject's will is that of some other per- 
son ; he does as he is told, and his will, and even his percep- 
tions, are under the complete control of the operator. In the 
normal state of an individual the will has no power over the 
perceptions. He cannot, for instance, by any effort of his will, 
alter his perception of color or form, or change the impression 

1 " La folie du doute (avec delire du toucher)," Paris, 1875. 



32 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

which any one of the sensory organs produces in the percep- 
tional centre. 

Like others of the mental faculties, the will-power is greatly 
developed by education. 

While the will is certainly located in the brain, it is by no 
means certain that in some of the lower animals, at least, it is 
not also situated in the spinal cord. The acts which are wit- 
nessed in the frog after the head has been cut off, and with it, 
of course, the entire encephalon, are clearly volitional in char- 
acter, being adapted to the end in view, and such as the ani- 
mal would perform in its unmutilated state. But, while the 
brain is the chief, if not the only, seat of the will in man, we 
have no data by which we are authorized to localize it in any 
particular part of this organ. Probably each motor and idea- 
tional centre is, at the same time, also volitional ; but even 
this is merely an inference. 

By certain French physiologists it has been located in the 
pons Varolii, but without, in my opinion, sufficient warrant 
from facts. 

An idea of the relation of the will to perception and intel- 
lect and a volitional act will be obtained from the accompany- 
ing diagram (Fig. 4), in which a is the organ of sense ; b, the 

Fig. 4. 




nerve of transmission ; c, the perceptive ganglion ; d, fibres of 
transmission to e, ideational ganglion ; f, communicating fibres 
with g, volitional ganglion ; h, efferent nerve communicating 
with i, a muscle. An image of a blow about to fall on the 
finger is formed on the eye, a ; the image is transmitted by 



DIVISIONS OF MIND. 33 

the optic nerve, b, to the perceptive ganglion, c, where it 
becomes a perception; from c it passes through the white 
fibres of the brain, d, to e, an ideational centre, where it be- 
comes an idea, being comprehended, and the danger to the 
finger realized. At once the knowledge excites an impulse 
either in the ideational centre or in a contiguous one, g, 
through the intermediation of brain fibres, f; and this im- 
pulse — a volition — passes through the nerve 7i to the muscle i, 
and the hand is immediately withdrawn. 

The mind, therefore, as before stated, is a compound force 
evolved by the brain — or, rather, a collection of several forces 
— and its elements are perception, intellect, emotion, and will. 
The sun, likewise, evolves a compound force, and its elements 
are light, heat, and actinism. One of these forces — light — is 
made up of several primary colors ; and the intellect of man, 
one of the mental forces, is composed of faculties. It would 
be easy to pursue the analogy, but enough has been said to 
indicate how closely the relationship between brain and mind 
is that of matter and force. 

It is to be regretted that the present state of cerebral anat- 
tomy and physiology is such as to prevent our making any 
precise localizations of the several forces and faculties which 
go to make up the mind. I have only ventured to do that in 
a single instance — the optic thalamus as a centre for percep- 
tion — and even that is questioned by several eminent investi- 
gators. The evidence, however, appears to me so explicit on 
this point that I do not see how it is to be questioned. " Much 
has been done by the labors of Broca, Fritsch and Hitzig, Noth- 
nagel, Meynert, Ferrier, and others, in the direction of the 
localization of brain functions, but it has been almost entirely 
confined to the determination of the centres for speech and 
for motor impulses. 

Gall, Spurzheim, Combe, and others, made honest attempts 
to found the science of phrenology, and, if their localizations 
of the various faculties of the mind— perceptional, intellect- 

1 For the evidence serving to establish the matter in question, reference is 
made to Magendie, " Lecons sur le systeme nerveux," t. i, p. 103, et seq. ; Luys, 
"Recherches sur le systeme nerveux," pp. 198, 344, 346, Paris, 1865; Ritti, 
" Theorie physiologique de l'hallucination," p. 37, Paris, 1874 ; Fournie, " Re- 
cherches experimentales sur le fonctionnement du cerveau," Paris, 1873 ; also, 
a memoir by the writer, entitled, " Thalamic Epilepsy," in Neurological Contri- 
butions, No. 3, p. 1, New York, 1881, in which additional facts are submitted. 
3 



3± PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

ual, emotional, and volitional — had been established, we should 
have as complete a knowledge of psychological topography 
as could be desired ; but they built on insufficient data, and, as 
a consequence, phrenology as a science does not exist at the 
present time. We know, however, that the gray matter of 
the brain originates mental operations, and that possibly the 
gray matter of the spinal cord and of the sympathetic sys--; 
tern supplements the process, and, under certain circum- 
stances, especially in the lower animals, may, to a consider- 
able extent, take its place. 

We know, also, that the cortical substance of the brain is 
of far greater importance in the evolution of mind than any 
other portion of the nervous system, and that it is here that 
experimentation and other methods of investigation have the 
greatest prospect of obtaining positive results. It is certainly 
established that the brain is not a single organ, but consists of 
a congeries of organs with different functions. 

Owing to this fact of our ignorance of the relation exist- 
ing between the faculties of the mind and the different parts 
of the brain, and our consequent inability to construct a posi- 
tive system of cerebral physiology, it is equally beyond our 
power to propose a classification of the phenomena of insan- 
ity based upon morbid anatomy and pathology. We are, 
therefore, driven to either a psychological or a clinical ar- 
rangement, or such a combination of the two as will best serve 
the purposes of study, till such time as we may become so 
thoroughly acquainted with the anatomical structure of the 
brain and its physiology as will admit of a more scientific 
system. 



CHAPTER III. 

GENERAL REMARKS ON TEE MENTAL AND PHYSICAL CONDITIONS 
INHERENT IN THE INDIVIDUAL WHICH INFLUENCE THE ACTION 
OF THE MIND. 

In individuals whose brains are well-formed, free from 
structural changes, and are nourished with a due supply — 
neither excessive nor deficient — of healthy blood, the per- 
ception, the intellect, the emotions, and the will act in a 
manner which within certain limits is common to mankind in 



INFLUENCE OF MENTAL AND PHYSICAL CONDITIONS. 35 

general. Slight changes in the structure or nutrition of the 
brain induce corresponding changes in the mind as a whole, 
or in some one or more of its parts or faculties, while profound 
alterations are accompanied by more severe and extensive 
mental disturbances. As no two brains are precisely alike, so 
no two persons are precisely alike in their mental processes. 
The argument, therefore, that if the mind resulted from the 
brain it would be the same in each individual instance, is 
simply ridiculous, and is made by those who have no concep- 
tion of the subject of which they write. Thus, M. Simonin, 1 
one of the most recent of the an tiphysiological psychologists, 
says: 

"If thought is secreted or produced exclusively by a ma- 
terial organ, this secretion ought to have a uniform charac- 
ter, and ought to be always identical with itself, as are other 
secretions, as the gastric juice secreted by the stomach, the 
pancreatic juice by the pancreas, etc. How is it, therefore, 
that this cerebral secretion, which ought always to be identi- 
cal with itself, as are the secretions of other organic materi- 
als, can produce such systems of thought, such calculations, 
such sublime arrangements, such speculations of the mind 
as are found in the works of Aristotle, Leibnitz, Lavoisier, 
Humboldt, Cuvier, Arago, Agassiz, etc. ? " 

To this absurd question I would reply by remarking that, 
if M. Simonin' s brain had been exactly like that of Aristotle, 
his thoughts would also have been exactly like Aristotle's, when 
evolved by like causes acting under like circumstances. But 
as M. Simonin's brain is certainly very different from that of 
the Greek philosopher, so also is the product of his brain dif- 
ferent. And I would say, further, that M. Simonin's assump- 
tion that the gastric juice and other secretions are alike in all 
men is as erroneous as are most of the other views contained in 
his book. No two persons ever lived in whom any one secre- 
tion possessed exactly the same composition in each, and 
hence it is that one man will digest with impunity things 
which another man's stomach instantly rejects. If M. Simo- 
nin has studied cerebral anatomy, and has ever compared two 
brains — and, being a psychologist whose faith is stronger than 
his love for facts, he probably disdains any such proofs — he 
has certainly discovered that there is as much dissimilarity 
between them as there is between any two peach-trees. How, 

1 " Histoire de la psychologie," etc., Paris, 1879, p. 391. 



36 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

then, can the product of two such brains — mind — be alike in 
both? 

But mind is not a fluid secretion, to be compared to the 
gastric juice. It is a force produced by nervous action. As a 
galvanic battery evolves galvanism, so the brain evolves mind. 
If the battery is good, the galvanism is good ; if the battery is 
bad, the galvanism is bad. If the gas is good, we get a good 
light ; if the gas is bad, we get a bad light. And, if the brain 
is good, the mind will certainly be good ; and, if the brain is 
bad, the mind will just as surely be bad. As no two persons 
ever looked exactly alike, it would be the height of absurdity 
to expect that any two hearts, or livers, or stomachs, or brains, 
would be alike. 

It would be difficult to find a passage of the same length 
containing more erroneous statements and false inferences 
than the following : l 

"If thought is a pure material secreted by the brain, the 
product should not be capable of causing a complete disorgan- 
ization of the human body. Neither the pancreatic juice nor 
the other visceral secretions ever produce a sudden disorganiza- 
tion. How can the materialistic atheists (mater ialistes-atMes) 
explain certain facts with which every one is familiar ? 

"A father, for example, has an only son whom he tenderly 
loves. This son belongs to an army in the field. The father 
reads one day that this son has been killed in battle. The in- 
telligence produces in him such a disturbance that he dies 
suddenly, as if struck by lightning. 

"Every sensation, whatever it may be, causes a thought in 
the brain. The news has caused a thought in the brain of the 
father, and this thought has instantly deprived him of life. 
Was this thought pure matter ? and why did it cause the fa- 
ther to pass from life to death % How can it be that the brain 
can secrete such murderous thoughts \ " 

If M. Simonin is not totally ignorant of all vital phenom- 
ena, he must know that, in such a case as the one he sup- 
poses, the heart has stopped beating in consequence of the 
overpowering effect of a strong emotion. I have seen rabbits 
and birds die in like manner from fear, and M. Simonin 
denies that they have souls. 

And he ought to know that the secretions do, under certain 
circumstances, become so poisonous as to cause instant death. 

1 Op. et loc. cit. 



INFLUENCE OF MENTAL AND PHYSICAL CONDITIONS. 37 

The milk of a nursing mother may, through the influence of 
great grief, kill the sucking infant with as much suddenness 
as the father was killed when he heard of his son's death. 
Thus, Bouchut 1 cites the case of a woman who, much ex- 
cited by the danger which her husband incurred during a 
quarrel with a soldier, who was about to use his sword, gave 
her breast a short time afterward to her child, aged eleven 
months, and in good health. The infant took a few mouth- 
fuls of her milk, was seized immediately with trembling and 
panting, and died in a few minutes. 

Dr. Carpenter 9 quotes from Mr. Wardrop the case of a 
mother from whom he had removed a small tumor. All went 
on well until she fell into a violent passion, and the child, 
being suckled soon afterward, died in convulsions. Many 
additional instances might readily be adduced. 

It is well known, also, that the saliva of man may, through 
the power of strong emotions, like anger or terror, become so 
venomous as to cause death to those on whom it is inoculated. 

Finally, it might be suggested to M. Simonin, and those 
who think with him, that it is no more surprising for death 
to be caused by a strong emotion originating through the 
action of the brain than it would be for a like fatal result to 
come from a murderous soul. 

There are differences, therefore, in the minds of men de- 
pending upon differences in their brains. These may be inhe- 
rent in the individual, reaching him through a long line of 
ancestors, or they may be acquired through the action of 
extraneous influences upon him ; or, again, they may be such 
as normally act upon him in the due and regular course of 
his life. Thus, the brain of a man is different from that of a 
woman, and there are differences in the resultant mental prod- 
ucts. The brain of a child varies in many essential respects 
from that of an adult, and, as a consequence, the mind is dif- 
ferent. Some persons are what is called eccentric, others have 
peculiar habits and idiosyncrasies, others are geniuses. Tem- 
perament, hereditary influence, and constitution, are likewise 
disturbing factors. So long, however, as the individual pe- 
culiarities of mentality are not directly at variance with the 
average workings of the human mind, or with the person's 

1 " Hygiene de la premiere enfance," etc., Paris, 1862, p. 177. 

2 "Cyclopaedia of Anatomy and Physiology," vol. iv, Part I, art. " Secre- 
tion, v p. 465. 



38 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

own methods of normal mind-action, lie is sane. If they are 
at variance, he is insane. 

But, within the limits of mental health, marked irregulari- 
ties are met with in the action of different parts of the mind. 
Thus, some persons are noted for never perceiving things as the 
majority of people perceive them. Others are weak in judg- 
ment, defective in memory, feeble in powers of application, 
or vacillating in their opinions; others have the emotional 
system inordinately or deficiently developed ; others, a,gain, are 
lacking in volitional power — in the ability to perform certain 
acts, or to refrain from others, which their reason tells them 
should be accomplished or omitted, or to follow a definite 
course of action which they know to be expedient and wise. 

In works on insanity, the several influences and conditions 
to which I refer have not, it appears to me, received due at- 
tention. I propose, therefore, to bring the chief of them to 
the notice of the reader, premising that no factor which can 
even in a remote degree influence the mental processes of an 
individual and no state of being which is liable to develop 
into insanity are unworthy the consideration of those who 
propose to study the subject of mental aberration. 



CHAPTER IV. 

ECCENTRICITY. 

Persons whose minds deviate in some one or more notable 
respects from the ordinary standard, but yet whose mental 
processes are not directly at variance with that standard, are 
said to be eccentric. Eccentricity is generally inherent in the 
individual, or is gradually developed in him from the opera- 
tion of unrecognized causes as he advances in years. If an 
original condition, it may be shown from a very early period 
of life, his plays, even, being different from those of other 
children of his age. Doubtless it then depends upon some 
peculiarity of brain structure, which, within the limits of the 
normal range, produces individuality of mental action. 

But eccentricity is not always an original condition, for, 
under certain circumstances, it may be acquired. A person, 
for instance, meets with some circumstance in his life which 



ECCENTRICITY. 39 

tends to weaken his confidence in Imman nature. He accord- 
ingly slmns mankind, by shutting himself up in his own house 
and refusing to have any intercourse with the inhabitants of 
the place in which he resides. In carrying out his purpose 
he proceeds to the most absurd extremes. He speaks to no 
one he meets, returns no salutations, and his relations with 
the tradesmen who supply his daily wants are conducted 
through gratings in the door of his dwelling. He dies, and 
the will which he leaves behind him is found to devote his 
entire property for the founding of a hospital for sick and 
ownerless dogs, " the most faithful creatures I have ever met, 
and the only ones in which I have any confidence." 

Such a man is not insane. There is a rational motive for 
his conduct — one which many of us have experienced, and 
which has, perhaps, prompted us to act in a similar manner, 
if not to the same extent. 

Another is engaged in vast mercantile transactions, requir- 
ing the most thorough exercise of the best faculties of the 
mind. He studies the markets of the world, and buys and 
sells with uniform shrewdness and success. In all the rela- 
tions of life he conducts himself with the utmost propriety 
and consideration for the rights and feelings of others. The 
most complete study of his character and acts fails to show 
the existence of the slightest defect in his mental processes. 
He goes to church regularly every Sunday, but has never been 
regarded as a particularly religious man. Nevertheless, he has 
one peculiarity. He is a collector of Bibles, and has several 
thousand, of all sizes and styles, and in many languages. If 
he hears of a Bible, in any part of the world, different in any 
respect from those he owns, he at once endeavors to obtain it, 
no matter how difficult the undertaking, or how much it may 
cost. Except in the matter of Bibles he is disposed to be 
somewhat penurious— although his estate is large— and has 
been known to refuse to have a salad for his dinner on account 
of the high price of good olive-oil. He makes his will, and 
dies, and then it is found that his whole property is left in 
trust to be employed in the maintenance of his library of 
Bibles, in purchasing others which may become known to the 
trustees, and in printing one copy, for his library, of the book 
in any language in which it does not already exist. A letter 
which is addressed to his trustees informs them that, when 
he was a bov, a Bible which he had in the breast-pocket of 



40 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

his coat preserved his life by stopping a bullet which another 
boy had accidentally discharged from a pistol, and that he 
then had resolved to make the honoring of the Bible the duty 
of his whole life. 

Neither of these persons can be regarded as insane. Both 
were the subjects of acquired eccentricity, which, in all likeli- 
hood, would have ensued in some other form, from some other 
circumstance acting upon brains naturally predisposed to be 
thus affected. The brain is the soil upon which impressions 
act differently, according to its character, just as, with the 
sower casting his seed- wheat upon different fields, some springs 
up into a luxuriant crop, some grows sparsely, and some, 
again, takes no root, but rots where it falls. Possibly, if 
these individuals had lived a little longer, they might have 
passed the border-line which separates mental soundness from 
mental unsoundness ; but certainly, up to the period of their 
deaths, both would have been pronounced sane by all compe- 
tent laymen and alienists with whom they might have been 
brought into contact ; and the contest of their wills, by any 
heirs-at-law, would assuredly have been a fruitless under- 
taking. 

They chose to have certain ends in view, and to provide 
the means for the accomplishment of those ends. There were 
no delusions, no emotional disturbance, no hallucinations or 
illusions, and the will was normally exercised to the extent 
necessary to secure the objects of their lives. At any time 
they had it in their power to alter their purposes, and in that 
fact we have an essential point of difference between eccen- 
tricity and insanity. We may regard their conduct as singu- 
lar, because they made an unusual disposition of their prop- 
erty ; but it was no more irrational than if the one had left his 
estate to the ' ' Society for the Prevention of Cruelty to Ani- 
mals," and the other had devoted his to sending missionaries 
to Central Africa. 

Two distinct forms of eccentricity are recognizable. In the 
one, the individual sets himself up above the level of the rest 
of the world, and, marking out for himself a line of conduct, 
adheres to it with an astonishing degree of tenacity. For him 
the opinions of mankind in general are of no consequence. 
He is a law unto himself ; what he says and does is said and 
done, not for the purpose of attracting attention or for obtain- 
ing notoriety, but because it is pleasing to himself. He does 



ECCEOTKICITY. 41 

not mean to be singular or original, but lie is, nevertheless, 
both. For every man is singular and original whose conduct, 
within the limits of reason and intelligence, differs from that 
of his fellow-men. He endeavors to carry out certain ideas 
which seem to him to have been overlooked by society to its 
great disadvantage. Society usually thinks differently ; but, 
if the promulgator is endowed with sufficient force of charac- 
ter, it generally happens that, eventually, either wholly or in 
part, his views prevail. All great reformers are eccentrics of 
this kind. They are contending for their doctrines, not for 
themselves. And they are not apt to become insane, though 
sometimes they do. 

The subjects of the other form occupy a lower level. They 
affect singularity for the purpose of attracting attention to 
themselves, and thus obtaining the notoriety which they crave 
with every breath they inhale. They dress differently from 
other people, wearing enormous shirt- collars, or peculiar hats, 
or oddly cut coats of unusual colors, or indulging in some 
other similar whimsicality of an unimportant character, in the 
expectation that they will thereby attract the attention or 
excite the comments of those they meet. 

Or they build houses upon an idea perhaps correct enough 
in itself, as, for instance, the securing of proper ventilation ; 
but in carrying it out they show such defective judgment that 
the complete integrity of the intellect may, perhaps, be a 
matter of question. Thus, one gentleman of my acquaintance, 
believing that fireplaces were the best ventilators, put four of 
these openings into every room in his house. This, however, 
was one of the smallest of his eccentricities. He wore a venti- 
lated hat, his clothing was pierced with holes, as were even 
his shoes ; and no one could be in his company five minutes 
without having his attention directed to these provisions for 
securing health. 

In addition to these advanced notions on the subject of 
ventilation, he had others equally singular in regard to the 
arrangement of the furniture in his dwelling and the care 
that was to be taken of it. Thus, there was one room called 
the "apostles' room." It contained a table that represented 
Christ, and twelve chairs, which were placed around it, and 
typified the twelve apostles ; one chair, that stood for Judas 
Iscariot, was covered with black crape. The floor of this room 
was very highly polished, and no one was allowed to enter it 



42 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

without slipping their shod feet into cloth slippers that were 
placed at the door ready for use. He had a library, tolerably 
large but of little value, and every book in it which contained 
Judas's name was bound in black, and black lines were drawn 
around the name wherever it occurred. Such eccentricity as 
this is not far removed from insanity, and is liable at any time, 
from some cause a little out of the common way, to pass over 
the line. 

Thus, a lady had since her childhood shown a singularity 
of conduct as regarded her table furniture, which she would 
have of no other material than copper. She carried this fancy 
to such an extent that even the knives and forks were of cop- 
per. People laughed at her, and tried to reason her out of her 
whim, but in vain. She was in her element as soon as atten- 
tion was directed to her fancy and arguments against it were 
addressed to her. She liked nothing better than to be afforded 
a full opportunity to discuss with any one the manifold ad- 
vantages which copper possessed as a material to be used in 
the manufacture of every article of table-ware. In no other 
respect was there any evidence of mental aberration. She 
was intelligent, by no means excitable, and in the enjoyment 
of excellent health. She had, moreover, a decided talent for 
music, and had written several passably good stories for a 
young ladies' magazine. An uncle had, however, died in- 
sane. 

A circumstance, trifling in itself, but one, as it afterward re- 
sulted, of great importance to her, started in her a new train 
of thought, and excited emotions which she could not control. 
She read in a morning paper that a Mr. Koppermann had ar- 
rived at one of the hotels, and she announced her determina- 
tion to call upon him, in order, as she said, to ascertain the 
origin of his name. Her friends endeavored to dissuade her, 
but without avail. She went to the hotel, and was told that he 
had just left for Chicago. Without returning to her home, she 
bought a railway ticket for Chicago, and actually started on 
the next train for that city. The telegraph, however, over- 
took her, and she was brought back from Rochester raving of 
her love for a man she had never seen, and whose name alone 
had been associated in her mind with her fancy for copper 
table furniture. She died of acute mania within a month. 
In this case erotic tendencies which had never been observed 
in her before seemed to have been excited by some very in- 



IDIOSYNCRASY. 43 

direct and complicated mental process, and these in their turn 
developed into general derangement of the mind. 

In another case, a young man, a clerk in a city bank, had 
for several years exhibited peculiarities in the keeping of his 
books. He was exceedingly exact in his accounts, but after 
the bank was closed always remained several hours, during 
which he ornamented each page of his day's work with ara- 
besques in different-colored inks. He was very vain of this 
accomplishment, and was constantly in the habit of calling 
attention to the manner in which, as he supposed, he had 
beautified what would otherwise have been positively ugly. 
His fellow-clerks amused themselves at his expense, but his 
superior officers, knowing his value, never interfered with him 
in his amusement. Gradually, however, he conceived the idea 
that they were displeased with him, and at last the notion 
became so firmly rooted in his mind that he resigned his posi- 
tion, notwithstanding the protestations of the directors that 
his idea was erroneous. Delusions of various other kinds 
supervened, and he passed into a condition of chronic insan- 
ity, in which he still remains. In most of the cases occurring 
under this head the intellectual powers are not of a high 
order, though there may sometimes be a notable development 
of some talent, or even a great power for acquiring learning. 
Painters, sculptors, musicians, mathematicians, poets, and 
men of letters generally, not infrequently exhibit eccentrici- 
ties of dress, conduct, manner, or ideas, which not only merely 
add to their notoriety, but often make them either the laugh- 
ing-stocks of their fellow-men or objects of fear or disgust to 
all who are brought into contact with them. 



CHAPTER. V. 

IDIOS Y N C RAS T. 

By idiosyncrasy we understand a peculiarity of constitu- 
tion by which an individual is affected by external agents in 
a manner different from mankind in general. Thus, some 
persons cannot eat strawberries without a kind of urticaria 
appearing over the body ; others are similarly affected by eat- 
ing the striped bass ; others, again, faint at the odor of cer- 



44: PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

tain flowers, or at the sight of blood ; and some are attacked 
with cholera-morbus after eating shell-fish — as crabs, lobsters, 
clams, or mnssels. Many other instances might be advanced, 
some of them of a very cnrions character. These several con- 
ditions are called idiosyncrasies. 

Begin, 1 who defines idiosyncrasy as the predominance of an 
organ, a viscns, or a system of organs, has hardly, I think, 
fairly grasped the subject, though his definition has influenced 
many French writers on the question. It is something more 
than this — something inherent in the organization of the indi- 
vidual, of which we only see the manifestation when the proper 
cause is set in action. We cannot attempt to explain why 
one person should be severely mercurialized by one grain of 
blue mass, and another take daily ten times that quantity for 
a week without the least sign of the peculiar action of mer- 
cury being produced. We only know that such is the fact ; 
and were we to search for the reason, with all the appliances 
which modern science could bring to our aid, we should be 
entirely unsuccessful. According to Begin's idea, we should 
expect to see some remarkable development of the absorbent 
system in the one case, with slight development in the other ; 
but, even were such the case, it would not explain the phe- 
nomena, for, when ten grains of the preparation in question 
are taken daily, scarcely a day elapses before mercury can be 
detected in the secretions, and yet hydrargysm is not pro- 
duced ; while when one grain is taken, and this condition fol- 
lows, the most delicate chemical examination fails to discover 
mercury in any of the fluids or tissues of the body. 

Begin's definition scarcely separates idiosyncrasy from 
temperament, whereas, according to what would appear to be 
sound reasoning, based upon an enlarged idea of the physi- 
ology of the subject, a very material difference exists. 

Idiosyncrasies are often hereditary and often acquired. 
Two or more may exist in one person. Thus, there may be 
an idiosyncrasy connected with the digestive system, another 
with the circulatory system, another with the nervous system, 
and so on. 

An idiosyncrasy may be of such a character as altogether 
to prevent an individual following a particular occupation. 
Thus, a person who faints at the sight of blood cannot be a 
surgeon ; another, who is seized with nausea and vomiting 

1 "Physiologie pathologique," Paris, 1828, t. i, p. 44. 



IDIOSYNCKASY. 45 

when in the presence of insane persons, cannot be a superin- 
tendent of a lunatic asylum— not, at least, if he ever expects 
to see his patients. Idiosyncrasies may, however, be over- 
come, especially those of a mental character. 

Millingen 1 cites the case of a man who fell into convulsions 
whenever he saw a spider. A waxen one was made, which 
equally terrified him. When he recovered, his error was 
pointed out to him. The wax figure was put into his hand 
without causing dread, and shortly the living insect no longer 
disturbed him. 

I knew a gentleman who could not eat soft crabs without 
experiencing an attack of diarrhoea. As he was exceedingly 
fond of them, he persevered in eating them, and finally, after 
a long struggle, succeeded in conquering the trouble. 

Individuals with idiosyncrasies soon find out their peculi- 
arities, and are enabled to guard against any injurious result 
to which they would otherwise be subjected but for the teach- 
ings of experience. 

Idiosyncrasies may be temporary only — that is, due to an 
existing condition of the organism, which, though natural or 
morbid, is of a transitory character. Such, for instance, are 
those due to dentition, the commencement or the cessation of 
the menstrual function, pregnancy, etc. These are frequently 
of a serious character, and require careful watching, especially 
as they may lead to derangement of the mind. Thus, a lady, 
Mrs. X, was at one time under my professional care, who, at 
the beginning of her first pregnancy, acquired an overpower- 
ing aversion to a half-breed Indian woman who was employed 
in the house as a servant. Whenever this woman came near 
her she was at once seized with violent trembling, which ended 
in a few minutes with vomiting and great mental and physical 
prostration, lasting several hours. Her husband would have 
sent the woman away, but Mrs. X insisted on her remaining, 
as she was a good servant, in order that she might overcome 
what she regarded as an unreasonable prejudice. The effort 
was, however, too much for her, for, upon one occasion when 
the woman entered Mrs. X's apartment rather unexpectedly, 
the latter became greatly excited, and, jumping from an open 
window in her fright, broke her arm, and otherwise injured 
herself so severely that she was for several weeks confined to 
her bed. During this period, and for some time afterward, 
1 "Curiosities of Medical Experience," London, 1837, vol. ii, p. 246. 



46 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

she was almost constantly subject to hallucinations, in which 
the Indian woman played a prominent part. Even after her 
recovery the mere thought of the woman would sometimes 
bring on a paroxysm of trembling, and it was not till after 
her confinement that the antipathy disappeared. 

Millingen 1 remarks that certain antipathies, which in real- 
ity are idiosyncrasies, appear to depend upon peculiarities of 
the senses. Rather, however, they are due to peculiarities of 
the ideational and emotional centres. The organ of sense, in 
any one case, shows no evidence of disorder ; neither does the 
perceptive ganglion, which simply takes cognizance of the 
image brought to it. It is higher up that the idiosyncrasy 
has its seat. In this way we are to explain the following cases 
collected by Millingen : 

" Amatus Lusitanus relates the case of a monk who fainted 
when he beheld a rose, and never quitted his cell when that 
flower was blooming. Scaliger mentions one of his relatives 
who experienced a similar horror when seeing a lily. Zim- 
mermann tells us of a lady who could not endure the feeling 
of silk and satin, and shuddered when touching the velvety 
skin of a peach. Boyle records the case of a man who felt a 
natural abhorrence to honey ; without his knowledge some 
honey was introduced in a plaster applied to his foot, and the 
accidents that resulted compelled his attendants to withdraw 
it. A young man was known to faint whenever he heard the 
servant sweeping. Hippocrates mentions one Kicanor, who 
swooned whenever he heard a flute ; even Shakespeare has 
alluded to the effects of the bagpipes. Julia, daughter of 
Frederick, King of Naples, could not taste meat without seri- 
ous accidents. Boyle fainted when he heard the splashing of 
water ; Scaliger turned pale at the sight of water-cresses ; Eras- 
mus experienced febrile symptoms when smelling fish ; the 
Duke d'Epernon swooned on beholding a leveret, although a 
hare did not produce the same effect ; Tycho Brahe fainted 
at the sight of a fox ; Henry III of France at that of a cat ; 
and Marshal d'Albret at a pig. The horror that whole fami- 
lies entertain of cheese is generally known." 

He also cites the case of a clergyman who fainted whenever 
a certain verse in Jeremiah was read, and of another who ex- 
perienced an alarming vertigo and dizziness whenever a great 
height or dizzy precipice was described. In such instances 

1 Op. citj p. 246. 



IDIOSYNCRASY. 47 

the power of association of ideas is probably the most influen- 
tial agent in bringing about the climax. There is an obvious 
relation between the warnings given by the prophet in the one 
case, and the well-known sensation produced by looking down 
from a great height in the other, and the effects which fol- 
lowed. 

Our dislikes to certain individuals are often of the nature 
of idiosyncrasies, which we cannot explain. Martial says : 
"Non amo te, Sabidi, nee possum dicere quare ; 
Hoc tantum possum dicere, non amo te " ; 
or, in our English version : 

"I do not like you, Doctor Fell, 
The reason why I cannot tell ; 
But this I know, and that full well — 
I do not like you, Doctor Fell. " 

Some conditions often called idiosyncrasies appear to be, 
and doubtless are, due to disordered intellect. But they 
should not be confounded with those which are inherent in 
the individual and real in character. Thus, they are frequently 
merely imaginary, there being no foundation for them except 
in the perverted mind of the subject ; at other times they are 
induced by a morbid attention being directed continually to 
some one or more organs or functions. The protean forms 
under which hypochondria appears, and the still more varied 
manifestations of hysteria, are rather due to the reaction ensu- 
ing between mental disorder on the one part, and functional 
disorder on the other, than to that quasi normal peculiarity of 
organization recognized as idiosyncrasy. 

Thus, upon one occasion I was consulted in the case of a 
lady who it was said had an idiosyncrasy that prevented her 
drinking water. Every time she took the smallest quantity 
of this liquid into her stomach it was at once rejected, with 
many evident signs of nausea and pain. The patient was 
strongly hysterical, and I soon made up my mind that either 
the case was one of simple hysterical vomiting, or that the 
alleged inability was assumed. The latter turned out to be 
the truth. I found that she drank in private all the water 
she wanted, and that what she drank publicly she threw up 
by tickling the fauces with her finger-nail when no one was 
looking. 

The idiosyncrasies of individuals are not matters for ridi- 
cule, however absurd they may appear to be. On the contrary, 



48 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

they deserve, and should receive, the careful consideration of 
the physician, for much is to be learned from them, both in 
preventing and treating diseases. In psychiatrical medicine 
they are especially to be inquired for. It is not safe to dis- 
regard them, as they may influence materially the character of 
mental derangement, and may be brought in as efficient agents 
in the treatment. 



CHAPTER VI. 

GENIUS. 

The inherent tendency which some individuals have for 
original work of a high order, in any department of literature, 
science, or art, is called genius. Briefly it may be defined to 
be a power of invention. Great geniuses are rarely met with, 
but persons born with the capacity for original thought in 
some new direction, and the energy to make their way to 
somewhere near the top of the ladder they may attempt to 
climb, are, fortunately for mankind, by no means rare. There 
will not probably be more than one Wagner in a generation ; 
but there will be many Yerdis, Gounods, Bachs, and Meyer- 
beers. 

The mental operations and results of a great genius are 
not like those of mankind in general, but the differences are 
within the normal range, and consist mainly in the fact that 
they are such as others are not accustomed to, merely because 
they are new. They are in advance of their time, and hence 
often induce the belief that their possessor is insane. Most 
original minds have to encounter this objection at some time 
or other of their career ; and, of course (and logically), the 
more striking and extravagant are the ideas they enunciate, 
the more loudly is the allegation of insanity uttered against 
them. Two or three hundred years ago they were accused of 
sorcery, witchcraft, or ungodliness, and were in danger of the 
prison or the stake. Sorcery and witchcraft have disappeared 
from the indictment, but ungodliness still remains, and lunacy 
has been added, to stand as prominent charges made against 
almost every one whose mind is in advance of the ordinary 
herd — and made, too, by persons of more than average com- 
mon sense and education. It appears, therefore, that the 



GENIUS. 49 

mere fact of an individual deviating, so far as his mode of 
thought is concerned, in any notable respect from the path 
generally followed by mankind, is sufficient to excite the sus- 
picion of insanity. Such deviation is regarded as a reproach, 
an insult, to the race, which no one has a right to offer. It is 
never exhibited by persons of mere talent, for talent follows 
the beaten road, though it follows it well. But genius dis- 
dains to be fettered ; it has a contempt for precedent ; it loaths 
the dull uniformity in which commonplace minds delight, 
and never rests till it has struck out a road for itself. 

If, three hundred years ago, any one had announced that 
he had discovered a method by which messages could be sent 
under an ocean three thousand miles wide in a few seconds, 
and another had claimed that, by a system he had devised, 
persons a hundred miles apart could converse together as 
readily as though they stood face to face, they would at first 
have been objects of derision and pity. If they had persisted, 
with all the enthusiasm which animates men with genius, in 
urging the truth of their inventions, and in asking for means 
to demonstrate them to the world, they would undoubtedly 
have been imprisoned as agents of the devil and corruptors of 
morals, or as blasphemers against the immutable laws of 
the Deity. If a man were in our own time to declare that he 
had invented a process by which a person could be in two 
places a hundred miles apart at the same instant, and were 
to show by his conduct that he had full faith in his assertion, 
he would certainly be considered a lunatic ; and, if he made 
himself anyways troublesome to his friends and relations, an 
insane asylum would ere long receive him within its walls. 
Nevertheless, to those who know nothing of physics, his claim 
would be no more preposterous than either of the others, 
yet both of these have been realized, and their realizers are 
geniuses. Three hundred years from now those who come 
after us may be ashamed of their ancestors for doubting that 
a person can be in two places remote from each other at the 
same time. 

The discrimination of the very highest flights of genius 
from insanity is a difficult, and at times an impossible, under- 
taking, for they may exist in one and the same person. If the 
distinction is to be made, it will be from the careful study of 
all the characteristics of the alleged genius or lunatic. The 
latter will generally show signs of mental derangement in 



50 PHYSIOLOGY AND PATHOLOGY OF THE MIND 

more than one direction, and will exhibit that inability to give 
long- sustained attention to any one subject which is so marked 
a symptom of insanity. The former will usually be consistent 
in the one thing which makes him original, whether it be in 
the work which he does or which he proposes to do. The 
imagination plays an important part in the mental operations 
of the man of genius and of the lunatic, but the one makes % 
use of this faculty for the accomplishment of the objects he 
has in view, while the other becomes its slave, and is led 
hither and thither by its vagaries. 

At the same time, though great genius and insanity are 
by no means to be regarded as necessarily closely related, there 
is no doubt that some of those who have made their mark in 
the world's progress by their transcendent powers of originality 
and invention have touched closely on the border line, while 
some again have crossed it. Eccentricity and genius often 
coexist in the same person, and this fact has served in the 
minds of some writers as a reason for regarding genius as a 
morbid mental manifestation. "Genius is a neurosis," says 
M. Moreau (de Tours), l and Dry den has declared that 

" Great wit to madness nearly is allied." 
No one can read the life of that great genius, Benvenuto Cel- 
lini, without reaching the conclusion that in him the two con- 
ditions were united. Martin Luther had hallucinations of 
sight and of hearing ; Pascal constantly saw a yawning preci- 
pice at his side ; Napoleon Bonaparte pointed out his star to 
General Rapp, and declared that it guided him in all his 
undertakings. Still, we would scarcely say that either of these 
men was insane ; it is quite certain that all of them were by 
nature strongly predisposed to insanity, and that the reason 
why they did not actually pass into that condition was be- 
cause no sufficiently powerful determining cause was brought 
into action upon them. 

In combating the opinion of M. Moreau (de Tours) that 
genius is a disease, M. Paul Janet a goes to the extreme and 
asserts that " genius is the human mind in its most healthy 
and most vigorous state." That this is true of genius as it has 
existed, and still exists, in some persons, is not to be ques- 
tioned ; but, with the examples of many others before us, we 
cannot fail, it appears to us, to arrive at the conclusion that 

1 " Psychologie morbide." 

a "Le cerveau et la pens6e," Paris, 1867, art. "Le g6nie et la folie," p. 84. 



HABIT. 51 

more people of great genius, at one time or other of their lives, 
exhibit manifestations of insanity than do persons of ordinary 
mental faculties. And it is not to be doubted that the genius 
which prompts to exaltation in literature and the fine arts is 
more apt to be associated with or to end in insanity than that 
which leads to superiority in any one or more of the sciences. 
In literature and art the imagination is strained to the utmost 
if the highest standard of originality and excellence is to be 
attained, and the imagination is assuredly that faculty of the 
intellect which is least tolerant of straining. The genius, on 
the contrary, which is concerned with mathematics, astron- 
omy, or any one of the sciences or mechanical arts, deals with 
facts instead of fancies ; and there is nothing about facts and 
their study which in the least predisposes to mental derange- 
ment. The great biologists and chemists, for instance, who 
have become insane, are so few in number that I cannot at 
this moment recall a single one ; while among great poets, 
painters, novelists, and musicians, who have either with their 
genius shown symptoms of insanity, or who toward the close 
of life passed into fatuity, the names of Tasso, Burns, Swift, 
Mozart, Hayden, Walter Scott, Blake, and Poe at once come 
to mind. 

The practical lesson to be derived from all this is, that care 
should be taken that young persons who evince more than 
ordinary talent for any particular branch of literature, science, 
or art, should be encouraged to exercise their minds to some 
extent in other directions. The concentration of the intellect 
upon a single subject, while yet the individual has scarcely 
learned how to use his mind, can only be regarded as deplor- 
able. 



CHAPTER YII. 

EABIT. 



When a living being performs an act under the operation 
of certain impressions which are received, there is a tendency 
toward the performance of a similar act, if like influences are 
brought to bear upon the organism. Every time the act is 
performed, the disposition to repeat it becomes stronger, until 
at last the tendency is so firmly established that the act is 



52 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

accomplished without the reception of impressions of like 
character to those which originally gave rise to it, but solely 
through the force of the newly acquired power. If from any 
cause the act is impossible of performance, the impulse still ex- 
ists, and produces more or less unpleasant feeling in the mind, 
or sensation in the part of the body with which it is in relation. 

This disposition to repetition is not limited to physical 
acts ; it prevails in regard to almost every function of the 
body and mind, and forms often an important element in the 
production of disease. 

Habit, therefore, is periodicity, and may be denned as the 
disposition which the organism acquires from the frequent 
reception of certain impressions, the indulgence in certain 
modes of thought, or the performance of certain acts, to con- 
tinue in the accustomed course till some more powerful force 
intervenes. 

A person, therefore, who has dined for many years regu- 
larly at the same hour, experiences the sensation of hunger 
when the time for eating arrives ; the orator or writer who 
has long been in the habit of arranging his thoughts in a par- 
ticular way, or of making use of peculiar modes of expression, 
follows the familiar methods with such unfailing regularity 
that, if he has spoken or written much, his style is at once rec- 
ognized by those who have given it their attention ; and the 
workman, who for years has observed a certain order or se- 
quence in the performance of his duties, continues the system 
unchanged throughout his whole life. 

But all these and other like habits may be broken up. 
The person who has dined habitually at six o'clock is taken 
ill, and, attributing his sickness to the fact of eating late in 
the day, changes his dinner-hour to one nearer noon. The 
orator or writer, finding that his speeches or essays are not so 
well received by the public as he would wish, alters his line 
of thought and characteristic phraseology to others which he 
thinks will be more effective ; and the workman, losing his 
position, obtains employment in another shop where a change 
in his methods becomes necessary. Such changes are, how- 
ever, not accomplished without considerable trouble, and 
sometimes with great suffering. 

An instance cited by Dr. Carpenter ' will recall many simi- 
lar ones to the reader. 

1 "Principles of Mental Physiology," etc., London, 1874, p. 354. 



HABIT. 53 

" The first child of a young mother was accustomed, before 
being put into his cradle for his mid-day sleep, to be 'hushed 
off ' in the arms of his mother or his nurse. But, having been 
told that this was an undesirable practice, his mother, wishing 
to break him of the habit, one day laid him down awake in 
his cradle and remained behind the head of it, so as to be out 
of the infant's sight. He screamed so long and so violently 
that several times she almost relented, fearing that he would 
injure himself ; but she had firmness to persevere, and, after a 
while, the child cried himself to sleep. Xext day the scream- 
ing fit was much shorter, and on the following day shorter 
still ; and in a few days the child ceased to cry when laid 
down, and never did so again." 

It is a well-known fact that the impressions or conse- 
quences which result from the action of certain agents are 
less marked as the operation of the cause is repeated. Thus, 
the system becomes habituated to the action of alcohol, 
opium, and many other substances, so that while a small quan- 
tity will, in the first instance, produce the characteristic result, 
the dose must be larger each time that it is taken, or be more 
frequently repeated, in order that a corresponding effect shall 
be produced. 

There are many noxious agents to the action of which the 
system may become so habituated by frequent repetition or 
the continuation of their action that no injurious results fol- 
low, when, without the protection thus afforded, disease, or 
even death, would be produced. Persons living in a malarious 
district, and who are thereby constantly exposed to the dele- 
terious emanations of the locality, are often, in time, so har- 
dened to the influence that it fails to cause its ordinary effects, 
while, as regards those newly arriving in the region, its power 
to do harm remains unabated. Acclimation is nothing but 
the acquisition of immunity from disease by habitual expos- 
ure to the morbific elements of some particular place. 

In like manner, a perception, an emotion, or a thought, 
which, when first experienced, caused a good deal of mental 
and physical disturbance, by repetition loses little by little 
the energy it once possessed, and scarcely excites a ripple in 
the usually placid mind or body of the individual. 

The influence of habit over the ordinary operations of the 
economy is constantly seen ; the sensations of hunger and 
thirst are experienced at stated periods of the day, because, 



5± PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

by frequently eating or drinking at those times, the system, 
as it were, expects a repetition, and hence the regular recur- 
rence of the feelings in question. The action of the same law 
is seen in the periodical return of the desire to evacuate the 
bowels at the same hour, when by habit we have become ac- 
customed to the act at that time. So with the desire for 
sleep, the hour of awaking, and the inexpressible sensations 
excited by the want of the usual cigar or alcoholic stimulant, 
with many others which must be familiar to every reader. 

The manners and customs of nations are mainly the result 
of habit, continued through a long succession of generations. 
It; is as difficult to alter them as it is to change a long-estab- 
lished habit of the individual organism. 

Some persons are more under the influence of habit than 
others ; they acquire a habit more quickly, and lose it with 
less facility. So strong are the unpleasant feelings excited 
by any interruption in the regular course of their habits that 
they will endure the greatest inconveniences to indulge them. 
I knew a gentleman whose custom it was to touch a certain 
tree — on the road from his house to the railway station, a dis- 
tance of about five miles — as he daily went to his place of 
business. On one occasion, through absence of mind, he neg- 
lected this action, and rode several hundred yards before he 
discovered his omission. Though feeling annoyed, he con- 
tinued his journey ; but the uncomfortable sensation became 
too strong for him to endure it any longer, and, after having 
ridden nearly two miles past the tree, he galloped back, at the 
risk of missing the train, and touched it as usual. 

Many persons, as is well known, have great difficulty in get- 
ting to sleep in any other bed than that to which they have 
become accustomed. No matter how luxurious the bed may 
be, sleep is effectually banished, often for several hours, and 
sometimes for the whole night. 

In explanation of the essential cause of habit we can bring 
forward nothing very definite. We know that with inorganic 
matter a force once acquired will continue indefinitely, if no 
more powerful force interferes with it. A ball thrown into 
the air would continue in motion but for the influence exerted 
by gravity and friction. We can conceive of a similar law 
being in operation on organized matter. An impression is 
made upon the brain, and through the nervous system certain 
thoughts or actions ensue. The impression is not effaced with 



HABIT. 55 

the accomplishment of tlie resultant act ; something of it re- 
mains to be strengthened, perhaps, by a similar impression 
made the following day, at the same time, with similar results. 
The process is in some respects like the registering of impres- 
sions to constitute memory, differing mainly in the fact that 
there is no consciousness of the process, and that there is no 
voluntary effort made to recall the impressions. This course 
may continue from day to day until the associated thoughts 
or actions are produced without the original stimulus, and 
thus the habit is established. 

For instance, a person is induced to smoke a cigar after 
dinner. The inducement, whatever it may be, constitutes the 
impression made upon the brain. The persuasion of a friend, 
the desire to be sociable, or the idea that smoking would be 
beneficial to the health, prompts to the performance of the act, 
and the cigar is smoked. It is repeated for the same cause 
until at last the act of repetition begins to exercise its effect, 
and the original incentive is lost sight of in the more power- 
ful one which has taken its place. A want has been created. 
A habit has been fully formed, and it cannot be broken with- 
out violence both to mind and body. The oft-repeated im- 
pression has left its traces somewhere each time, until at last 
it assumes a local habitation and becomes permanently fixed 
in the organism, not to be lost except through some more 
powerful influence acting in a similar manner to the first. 

I have known several instances in which choreic affections 
have been acquired through a habit of imitating those who 
were thus disordered in their nervous systems. In one of 
these a boy mimicked the involuntary facial contortions from 
which a schoolmate suffered. He kept up the actions at in- 
tervals during the morning, and then discovered, to his great 
dismay, that he had lost the power of control over them, hav- 
ing, in fact, become himself the subject of facial spasms ex- 
actly like those of his prototype. Here the original excitation 
of the will, acting upon a peculiarly sensitive system of motor- 
cells, impressed them so strongly that, after a few repetitions 
of the volitional impulse, they were endowed with the power 
of carrying on the resultant movements through the force 
evolved by their own action. Several old ladies of strongly 
benevolent dispositions regarded it as resulting from a special 
dispensation of Providence. 

Stammering, which is a chorea of the muscles of speech, is 



56 PIIYSIOLOGY AND PATHOLOGY OF THE MIND. 

also sometimes produced by mimicry of those affected. In 
one case which came under my observation, the patient, a 
young man twenty years of age, had suffered for ten years 
from very severe stammering, which he had contracted by 
imitating the mode of speech of another boy, who could 
scarcely articulate a word with facility. 

The most striking instance of a disease being continued by 
habit is furnished by intermittent fever. There can be no 
doubt that, after the disease has been fairly established 
through the influence of malaria, the paroxysms occur with 
more or less regularity after removal to a healthy climate ; 
and this through the force of the habit, which has been in- 
duced by the frequent repetition of the attacks. Indeed, so 
strong is the power of habit over the phenomena which, taken 
collectively, are known as intermittent fever, that it is quite 
possible to produce the disease by artificial means. 

The very interesting experiment performed by M. Brachet 
affords us conclusive evidence on this point. This observer 
took a bath in the Seine every night at twelve o'clock toward 
the end of October, 1822. The procedure was continued for 
seven successive nights. After each bath he went to bed, cov- 
ered himself warmly, in a short time became very hot, and 
finally broke out in a profuse perspiration. Discontinuing 
his cold bathing at the expiration of the seven days, M. Bra- 
chet was very much surprised to find that, at the hour for 
taking his bath, he was attacked with shivering, fever, and 
perspiration in regular order, and not to be distinguished 
from an ordinary attack of ague. For six successive nights 
he was thus affected. On the seventh, about midnight, he 
was summoned to attend a case of labor. The ride heated 
him, the heat was continued by his standing for some time 
in front of the fire, and thus the fire was broken up. 

There is no doubt that epilepsy is often kept up by habit. 
Indeed, the occurrence of a single paroxysm from a non-con- 
tinuing cause, such as an undigested meal, or a splinter under 
the skin, is sufficient very frequently, in my experience, to 
cause a predisposition to other attacks, which may last 
through the whole life of the individual. 

Habits may be transmitted by hereditary influence through 
many successive generations. We are, perhaps, scarcely 
aware of the fact in all its relations, but a little attention to 
family histories will bring out many points well calculated to 



HABIT. 57 

enlarge our idea of the permanency and immutability charac- 
teristic of some mental and physical habits. 

Grirou de Bnzareingues * says that he had known a man 
who, lying in bed on his back, was in the habit of crossing 
his right leg over his left. One of his daughters had the same 
habit from birth. She constantly assumed this position in 
her cradle, notwithstanding the obstacles which the napkins 
offered. And he adds that he knows several girls who resem- 
ble their fathers, and who have habits which they have evi- 
dently inherited from them, and boys of whom the like is 
true as regards their mothers. 

Darwin 2 cites a case, on the authority of Mr. F. Galton, 
which is still more striking : " A gentleman of considerable 
position was found by his wife to have the curious trick, 
when he lay fast asleep on his back in bed, of raising his right 
arm slowly in front of his face up to his forehead, and then 
dropping it with a jerk, so that the wrist fell heavily on the 
bridge of the nose. The trick did not occur every night, but 
occasionally, and was independent of any ascertained cause. 
Sometimes it was repeated incessantly for an hour or more. 
The gentleman's nose was prominent, and its bridge often be- 
came sore from the blows which it received. At one time an 
awkward sore was produced that was long in healing, on ac- 
count of the recurrence night after night of the blows which 
first caused it. His wife had to remove the button from the 
wrist of his night-gown, as it made severe scratches, and some 
means were attempted of tying his arm. 

" Many years after his death his son married a lady who 
had never heard of the family incident. She, however, ob- 
served precisely the same peculiarity in her husband ; but his 
nose, from not being particularly prominent, has never as yet 
suffered from the blows. The trick does not occur when he is 
half asleep, as, for example, when dozing in his arm-chair; 
but the moment he is fast asleep it is apt to begin. It is, as 
with his father, intermittent, sometimes ceasing for many 
nights, and sometimes almost incessant during a part of every 
night. It is performed, as it was by his father, with his right 
hand. 

"One of his children, a girl, has inherited the same trick. 
She performs it likewise with the right hand, but in a slightly 

1 Cited by Ribot, "L'heredite," 2ieme ed., Paris, 1882, p. 58. 

2 "The Expression of the Emotions," London, 1872, p. 33, note. 



58 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

modified form ; for, after raising the arm, she does not allow 
the wrist to drop upon the bridge of the nose, but the palm 
of the half- closed hand falls over and down the nose, striking 
it rather rapidly. It is also very intermittent with this child, 
not occurring for periods of some months, but sometimes oc- 
curring almost incessantly." 

A gentleman informed me that his grandfather had become 
accustomed to wake up from sound sleep at twelve o'clock 
every night and drink a cup of tea, after which he would lie 
down and sleep quietly till morning. The father of my in- 
formant was a posthumous son, and his mother died in child- 
birth with him. He was English, and at an early age went 
to India with an uncle. One night, when he was about 
twenty years of age, he awoke suddenly with an intense de- 
sire for a cup of tea. He endeavored to overcome the long- 
ing, but finally, being unable to sleep, got up, and, proceeding 
to an adjoining room, made himself a cup of tea, and then, 
going back to bed, soon fell asleep. He did not mention the 
circumstance at that time ; in fact, it made no strong impres- 
sion on his mind, but the next night the awaking, the desire, 
and the tea- making were repeated. At breakfast the follow- 
ing morning he alluded to the fact that he had twice been 
obliged to rise in the middle of the night and make himself a 
cup of tea, and laughingly suggested that, perhaps, it would 
be as well for him in future to have the materials in his bed- 
room. His uncle listened attentively, and, when the recital 
was finished, said : " Yes, have everything ready, for you will 
want your tea every night ; your father took it at midnight 
for over twenty years, and you are like him in everything." 

His uncle was right ; the midnight tea-drinking became a 
settled habit. Several years afterward he returned to Eng- 
land, and there married. Of this marriage a son — my in- 
formant — was born, and six years subsequently the father 
died. The boy was sent to school till he was sixteen years 
old, when he was sent to Amsterdam as a clerk in the count- 
ing-house of his mother's brother, a banker of that city. 

He was kept pretty actively at work, and one night in 
particular did not get to bed till after twelve o'clock. Just 
as he was about to lie down the idea struck him that a cup of 
tea would be a good thing. All the servants had retired, so 
the only thing to do was to make it himself. He did so, and 
then went to bed. The next night he again had his tea, and 



HABIT. 59 

after that took it regularly, waking from sleep punctually for 
that purpose at twelve o'clock. Up to that time he had never 
been a tea-drinker, though he had occasionally tasted it. 
Writing home to his mother, he informed her that he had 
taken to the custom of drinking tea, but had acquired the 
habit of taking it at a very inconvenient hour — twelve o'clock 
at night. She replied, telling him that he had come honestly 
by his liking, for his father and grandfather had had exactly 
the same habit. Previous to the reception of this letter he 
had never heard of the peculiarity in his father's and grand- 
father's lives. 

Habitual indulgence in some powerful emotion or engross- 
ing train of thought is a very influential cause of insanity. 

The proper regulation of the habits conduces more to men- 
tal and physical well-being than perhaps any other factor. 
The ability of an individual to control those habits — which, 
when indulged in to moderation, are beneficial to the organ- 
ism, but to excess are injurious — is an indication not only of 
strong will-power, but is an important influence in preserving 
the health both of mind and body. All the appetites are 
more or less under the control of the will, and it is easy in 
youth or early manhood to bring them into proper subjection, 
whereas in mature age the matter is much more difficult, and 
with some persons impossible. As we shall see farther on, 
there is scarcely a form of mental derangement which may 
not be incurred by habitual over-indulgence in some one or 
more of the natural or acquired appetites. As regards purely 
mental habits, youth is the period during which they may be 
formed most readily, and with the best prospect of enduring 
for a lifetime. Then the faculties of the mind are developed 
with the greatest facility and brought into systematic and 
habitual action. That, therefore, is the best method of edu- 
cation which most effectually secures these ends. 

The matter may be summed up in the following words of 
Sir Henry Holland: 1 " The formation of new habits, how- 
ever, is not more important than is the control of those which 
are casually, and often injuriously, created by the accidents 
of life, or by individual passions or propensities. These must 
be governed by the mind, that they do not gain dominion over 
it. They form an alien power in possession, which it needs 
strong efforts, both of reason and resolution, to expel. To 

1 " Chapters on Mental Physiology," London, 1852, p. 232. 



60 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

create and maintain that ' vigor of mind which is able to con- 
test the empire of habit ' (Locke) may be rightly asserted as 
the chief end of all mental discipline." 

And the following from Lemoine : l " Habit has sometimes 
been branded with the name of routine, because, as it were, it 
forms all actions in the same mould, and often usurps the place 
of reason and the will. But it is not habit which deserves 
this reproach, and which arrests the progress of science or the 
perfectionment of life. It is the bad use which is made of it, 
the idleness of mind and of will, when the agent which has 
acquired by habit an increase of force and capacity for acting 
is contented to do with the least effort that which is most 
easily done, and not to employ this increase of power to per- 
form more difficult acts. If life, science, morality, civilization, 
progress of all kinds, are stopped at some point of their ca- 
reer, it is not habit which stands in the way ; it is some extra- 
neous cause which immobilizes at the same time that it arrests 
progress. There is nothing in the nature of habit, or in its 
laws, which can act as a cause of regression, of retardation, 
or of rest. It is essentially an augmentation of power, and it 
tends always to the elevation and the improvement of the 
human race." 

In the examination of lunatics, or suspected lunatics, the 
habits of the individual should form the subject of careful 
inquiry. Not only is much light thereby thrown upon the 
mental condition, but important data are supplied toward the 
formation of a correct prognosis. 



CHAPTER VHI. 

TEMPERAMENT. 

The subject of temperament, which at one time was an 
important factor in medical literature, fell a few years ago 
into unmerited neglect, to be revived quite lately to a position 
almost equal to that which it occupied among the ancients, and 
with much clearer ideas of its real value in biological science. 

The ancients laid very great stress on the doctrine of the 
temperaments, and on the influence which these conditions of 
1 "L'habitude et l'instinct; 6tude de psychologie comparee," Paris, 1875, p. 77. 



TEMPEKAMENT. 61 

the system are capable of exercising over diseases. Galen ar- 
ranged them into four classes, corresponding, as he supposed, 
to the four different liquids of the body, which, in their turn, 
represented the four elements — earth, air, fire, and water. 
The four humors were the bile, the blood, the back bile, and 
the lymph ; and hence he had the bilious, the sanguineous, 
the atrabilious, and the lymphatic or phlegmatic tempera- 
ments, according to the predominance of one or other of these 
fluids. 

We know, however, that no such connection as that sup- 
posed by Galen*really exists, yet the names given by him 
are still those which are in vogue. The individual of san- 
guine temperament, other things being equal, has no more 
blood than the one of phlegmatic temperament, nor less 
lymph ; neither can these fluids be regarded as at all influ- 
encing the mental constitution or the physical peculiarities. 
The same remarks may with truth be applied to the bile, so 
that there is no necessary or direct connection like that as- 
sumed by Galen. But there can be no doubt relative to the 
existence of certain mental and physical types which pre- 
sent distinct characteristics easily recognizable, so that, from 
an inspection of the aspect and general bodily construction, 
we are enabled to define with tolerable certainty the physical 
peculiarities. These types we call temperaments. 

Muller * defines temperament as a peculiar permanent con- 
dition or mode of mental reaction of the mind and organism. 
I cannot say that the definition is a very clear or satisfactory 
one, although perhaps sufficiently so to indicate the idea in- 
tended to be expressed. 

Temperament is rather the organic constitution dependent 
upon certain mental or physical peculiarities, innate or ac- 
quired. It is the specific difference which gives to persons, or 
groups of persons, their individuality. We can very readily 
perceive that it must influence very materially the predispo- 
sition to disease. And, in fact, when we come to consider the 
subject in all its bearings, and with the profundity of which 
it is worthy, we find it very difficult, if not impossible, to dis- 
tinguish between temperament and predisposition except by 
the one feature — that the latter embodies more than the former. 
And, as we can indicate, with considerable approach to correct- 

1 "Elements of Physiology," translated by William Baly, M. D., London, 
1842, vol. ii, p. 1406. 



62 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

ness, the intellectual character of the individual from the color 
of his hair, eyes, and complexion, the size and shape of his 
hands and feet, or the peculiarities of his pulse and respira- 
tion, so we are enabled, with equal facility, from a similar ex- 
amination, to designate the diseases to which he is specially 
liable. 

It is not, however, to be asserted that the temperaments 
are separated from each other by strictly defined lines. If 
they were, we should probably have more uniformity among 
authors in their classification. As it is, a very considerable 
diversity exists, some making but two, and others as high as 
seven. It is very much with temperaments as it is with the 
colors of the solar spectrum : they overlap each other, and give 
rise to certain compound temperaments which possess many 
of the characteristic marks of distinct conditions, but which 
may, without much difficulty, be separated into their original 
constituents. 

Cullen was able to see but two temperaments — the san- 
guineous and the choleric ; all others he regarded as combina- 
tions of these two. Begin, 1 with more propriety, recognizes 
three — the sanguineous, the lymphatic, and the nervous. I 
agree with several authors in admitting four — the sanguine- 
ous, the lymphatic or phlegmatic, the choleric, and the ner- 
vous. This division is that adopted by Devay, 2 and is one 
which appears to be founded on natural differences. In addi- 
tion, there is another, which some authors have described as 
distinct from all others — the insane temperament. This, how- 
ever, is, I think, only an excessive degree of development of 
the nervous. 

In examining a patient, very little attention is, as a rule, 
paid to the study of the temperament, although from this 
source a flood of light can always be obtained to assist in de- 
termining the diagnosis, the prognosis, and the treatment, and 
this is especially true of those diseases of the brain charac- 
terized by the existence of mental derangement. In seeking, 
therefore, to ascertain the particular temperament of an indi- 
vidual, it is necessary to take into consideration, not only his 
physical peculiarities, but also the mental characteristics he 
may possess. 

And, in making such an investigation, we should, as E-oyer- 

1 " Physiologie pathologique," Paris, 1828, t. i, p. 56. 

3 " Traits special d'hygiene des families," etc., Paris, 1858. 



TEMPERAMENT. 63 

Collard * declares, bear in mind that a temperament is a more 
or less permanent variety of health, and the conditions should 
be ascertained, not by examinations made of a single organ 
or fluid of the body, but of the blood and the nervous system. 
The characteristics of these are to a great extent indicated by 
the appearance, the bearing, and the habits of the individual ; 
but our inquiries may very advantageously extend beyond 
these points by employing the several instruments of pre- 
cision, which, when properly used, are of inestimable value 
in such determinations. 

The Sanguine Temperament. — This temperament is charac- 
terized by great activity of the circulatory and respiratory 
apparatus, and by marked vivacity of mind. The pulse is 
quick, strong, and bounding ; the complexion florid ; the hair 
red or chestnut color ; the eyes blue ; the hands and feet 
small ; the skin thin and fair ; the respiration active ; the di- 
gestion good ; the excretion from the skin abundant, while, 
owing to this latter cause, the urine is small in quantity and 
is high colored. The powers of endurance are very consider- 
able, though not so great as in the choleric temperament, not, 
however, so much from any physical defects as from mental 
peculiarities. The expression of countenance is cheerful and 
hopeful, and activity characterizes all the movements. 

In the mental constitution we see the same qualities dis- 
played — modified, of course, by the different material with 
which they are associated. There are the same restlessness 
and brilliancy, and, while any particular bent is followed, a 
good deal of energy is shown. The love of pleasure predomi- 
nates, but the pleasure must be frequently varied or satiety 
is soon produced. Inconstancy is a predominating feature. 
Good resolutions are formed but to be broken. Friendships 
are readily contracted, to be soon abandoned for others, which, 
in their turn, are speedily given up. In love, the individual 
of sanguine temperament is fickle and faithless, caring less 
for his honor than his pleasure. He engages in great under- 
takings without counting the cost, and, if unexpected diffi- 
culties arise, he soon becomes discouraged, unless he sees 
an ultimate advantage to himself from persevering. If suc- 
cess attends his efforts, as it often does, it is more on account 
of the rapidity of his actions than the consequence of any 

1 "Des temperaments considers dans leurs rapports avec la santeV' "Me- 
moires de Tacademie royale de medecine," t. x, 1843, p. 165. 



G± PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

well-laid plans, or else is the result of that u good luck" of 
which he is frequently the recipient. 

History furnishes many examples of distinguished persons 
of sanguine temperament. Marc Antony and Plato among 
the ancients ; Charles II, of England, Lorenzo di Medici, the 
Duke of Richelieu, and Murat, are instances of it. In this 
country, General Wayne and Henry Clay were good examples 
of this temperament. Shakespeare, in his inimitable character 
of Mercutio, has depicted it with masterly power. Poetry, 
painting, and sculpture have some of their most distin- 
guished cultivators among individuals of the sanguine tem- 
perament. 

Temperate climates afford the most striking instances of 
this form of temperament. We see this not only in the men- 
tal and physical characteristics of individuals, but in the his- 
tory of the nations which inhabit countries situated within 
the temperate zone. 

The female sex contains more representatives of it than the 
male, and youth more than adult age. 

The diseases to which persons of the sanguine tempera- 
ment are peculiarly disposed are those connected with the 
circulatory system. Thus, they are liable to functional and 
organic diseases of the heart, aneurisms, and haemorrhages. 
Contrary to the generally expressed opinion, I do not believe 
in any decided proclivity of individuals of this temperament 
to inflammatory affections. Activity of circulation is not fa- 
vorable to diseases of this character. 

While it cannot be said that the sanguine temperament 
predisposes to insanity, it modifies the symptoms in accord- 
ance with its influence over the mind and body in their nor- 
mal state. A person of sanguine temperament becoming in- 
sane is more apt to be affected with acute mania, or some 
other form of mental exaltation, in contradistinction to any 
variety of which mental depression is the characteristic feat- 
ure. They are not, however, even in their most excited mo- 
ments, so apt to perpetrate acts of violence as individuals of 
some of the other temperaments — the choleric, for instance. 
Being endowed with great vitality, the prognosis is more favor- 
able, other things being equal, in persons of sanguine tempera- 
ment affected with insanity than in others of different tem- 
peraments. 

Individuals of the sanguine temperament should abstain 



TEMPERAMENT. 65 

from stimulating articles of food and drink, and should con- 
fine themselves to a plain but nutritions diet. They should 
exercise freely in the open air, avoiding, as far as possible, the 
direct rays of the summer sun. Overheated and crowded 
apartments are also injurious. I have seen many cases of 
acute mania superinduced in persons of sanguine tempera- 
ment from a disregard of these simple precautions. There is 
with them generally a predisposition to cerebral hyperemia, 
which is very liable to be aggravated into reality, or even 
intense congestion or inflammation, by any one of the factors 
cited. 

The Lymphatic or Phlegmatic Temperament. — This tempera- 
ment is the direct opposite of the sanguine in almost every 
respect. The flesh of persons in whom it exists is flabby 
and soft ; the pulse is infrequent, weak, and languid ; the 
respiration slow ; the countenance pale or leaden color ; the 
eyes green or pale gray, and expressionless ; the hair very 
straight, and light-colored. The whole form is rounded, and 
lacking in that elasticity which characterizes the sanguine 
temperament. 

Mentally, the difference is equally striking. The intellect 
is slow to act ; ideas come with difficulty ; but there is by no 
means necessarily a deficient degree of intelligence, and, 
though matters may be comprehended and conclusions reached 
with a tardiness aggravating to those of quicker minds, they 
are fully as likely to be right in both as those who reason 
more promptly, and seem to arrive at a judgment with scarcely 
an effort. Undoubtedly, however, when the lymphatic tem- 
perament is excessively developed, there is often a sluggish- 
ness of the mental processes almost amounting to stupidity. 

The emotions are not easily roused into activity, and are 
rarely of an ennobling or energetic character. Courage is not 
a prominent attribute of lymphatic persons, and, though they 
may not run away at the approach of danger, it is more be- 
cause they do not at once understand its nature than from 
any high feeling of pride or honor. The memory is weak, 
and the power of application, or of concentrating the attention, 
inconsiderable. There is, therefore, a disinclination to reflect- 
ive study, or any mental or physical exertion. Men of this 
temperament have made but little sensation in the world's 
history. The part they have played has been quiet, unob- 
trusive, and even insignificant. 



66 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

But it is not to be supposed that this temperament has not 
its good side. Although prompting to slowness, there is often 
a perseverance which may compensate for a lack of rapidity. 
Friendships are not often contracted, but, when once formed, 
are frequently enduring, in a mild way. Great undertakings 
are rarely attempted, but those moderate ones which consti- 
tute the bulk of the operations of every-day life, and which: 
require neither brilliancy nor energy, are accomplished with- 
out bustle or confusion. 

As MuHer ' remarks, the subject of the phlegmatic tem- 
perament may be a very useful and trustworthy member of 
society. When rapid action is required, the phlegmatic per- 
son is less successful, and others leave him behind ; but, when 
no haste is desired and delay is admissible, he quietly attains 
his end while others have committed error upon error, and 
have been diverted from their course by their passions. The 
phlegmatic person knows his proper sphere, and does not tres- 
pass upon that of others, or come into collision with them. 
From this conduct, as well as from an orderly and steady 
course of action, in which he keeps his object in view and 
avoids self-deception, he derives a contented tone of mind, 
free alike from turbulent enjoyments and deep suffering. 
Cold and damp climates are those in which this temperament 
is generally encountered. 

Old age more frequently exhibits it than youth, and it is 
more often met with in women than in men. It is readily ac- 
quired under circumstances favorable to its production. A 
life in which there is little inducement to either bodily or 
mental exertion, especially if the surroundings, such as the 
temperature and humidity of the atmosphere, be propitious, is 
exceedingly apt to produce it even in persons of directly op- 
posite characteristics. 

The varieties of mental derangement wh^ch are especially 
liable to exist in persons of the phlegmatic temperament are 
a low grade of melancholia — the melancholie avec stupeur of 
the French — and acute dementia. If the subjects of this tem- 
perament become affected with acute mania, the mental and 
bodily excitement does not reach so high a plane as in those 
of the sanguine temperament. Their delusions are not of 
so gay a character, and generally relate to plots or designs 

1 " Elements of Physiology," edited by Dr. William Baly, London, 1842, vol. 
ii, p. 1408. 



TEMPERAMENT. 67 

against them by some real or imaginary persons. Instead, 
however, of wishing to fight their supposed injurers, as would 
the man of sanguine temperament, or sitting wringing their 
hands in anguish, as would he of the choleric temperament, 
the phlegmatic lunatic takes it all very quietly, and will talk 
of the malicious attempts which have been made upon his 
life without evincing the slightest anger or sorrow, and with 
even a pleasant smile on his countenance. 

Persons in whom the lymphatic temperament is strongly 
marked endure heat well, but cold badly. They should 
avoid excess at table, but may, with advantage, indulge to 
moderation in wines or malt liquors. Animal food should 
constitute a large proportion of their diet. 

The Choleric or Bilious Temperament. — The physical and men- 
tal characteristics of this temperament are exceedingly well 
marked. The complexion is dark, or sallow ; the hair black, 
or a dark brown ; the eyes black, or hazel ; the skin dry and 
not over-soft, except sometimes in women ; the flesh hard and 
firm ; the pulse hard, strong, and frequent ; the respiration 
deep and strong, and the whole form thin, tough, and capa- 
ble of enduring great fatigue without deleterious conse- 
quences. 

Mentally, the man of choleric temperament is characterized 
by firmness, decision, and determination. His mind is quick 
to form a judgment, his will active and powerful in the accom- 
plishment of his purposes, and his perseverance carries him 
over all difficulties. His emotions are vivid, but, when it 
suits his designs, he keeps them under due control. He is 
irritable, sensitive, and often vindictive, cruel, and unscrupu- 
lous. Bold in the conception of a project, constant and in- 
defatigable in its execution, it is among men of this tempera- 
ment that we find those who in different ages have governed 
the destinies of the world ; full of courage, boldness, and ac- 
tivity, all have signalized themselves by great virtues or great 
crimes, and have been the terror or admiration of the uni- 
verse. Such were Alexander, Csesar, Brutus, Mahomet, 
Charles XII, the Czar Peter, Cromwell, Sixtus V, and Car- 
dinal Richelieu. 

" As love is in the sanguine, so ambition is in the bilious, 
the governing passion. Observe a man who, born of an ob- 
scure family, long vegetates in the lower ranks. Great shocks 
agitate and overthrow empires ; at first a secondary actor in 



63 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

those great revolutions which are to change his destiny, the 
ambitions man hides his designs from all, and by degrees 
raises himself to the sovereign power, employing to preserve 
it the same address with which he raised himself to it. This 
is, in a few words, the history of Cromwell and of all usurpers. 

"To attain to results of such importance, the profoundest 
dissimulation and the most obstinate constancy are equally 
necessary ; these are, further, the most eminent qualities of 
the bilious. No one ever combined them in higher perfection 
than that famous pope who, slowly travelling on toward the 
pontificate, went, for twenty years, stooping and talking for- 
ever of his approaching death, and who, at once proudly 
rearing himself, cries out : i I am pope ! ' petrifying with aston- 
ishment and mortification those whom his artifice had de- 
ceived into his party. 

"Such, too, was Cardinal Kichelieu, who raised himself 
to a rank so near to the highest, and was able to maintain 
himself in it ; feared by the king, whose authority he estab- 
lished ; hated by the great, whose power he destroyed ; 
haughty and implacable toward his enemies, ambitious of 
every sort of glory." * 

Among men of science and letters who have possessed the 
choleric temperament are Dante, Newton, Spinoza, Galileo, 
Milton, Pascal, Tasso, Rousseau, Goethe, and Calvin. In this 
country the most distinguished representatives of the chol- 
eric temperament have been Mr. Calhoun, Mr. Webster, Mr. 
Lincoln, Generals Grant, Sherman, Sheridan, and Lee, and 
Mr. Jefferson Davis. 

Individuals of the choleric temperament are, perhaps, 
more subject to insanity than those of any other, unless it be 
the nervous, next to be described. The variety to which they 
are especially liable is melancholia in all its forms, and it 
sometimes assumes with them the most terrible of all the 
phases of mental derangement — the suicidal and homicidal. 
The delusions which are most frequently met with in them 
are those which relate to injuries done them by others, or hor- 
rible crimes which they have themselves perpetrated. Often 
they refer to religious subjects, and to the state of eternal 
damnation into which their souls are to be plunged on ac- 
count of the enormity of their sins. The idea that they have 

1 RicherancTs "Elements of Physiology," edited by Chapman, Philadelphia, 
1818, p. 583. 



TEMPERAMENT. 69 

committed the " unpardonable sin" is a very common delu- 
sion with this class of lunatics, and they will often walk the 
floor for days and nights at a time, wringing their hands, 
moaning, and sobbing, at the thought ever present of the 
awful punishment in store for them in the world to come. I 
know of no one point in the whole range of theology which 
has inflicted more injury upon the human mind, and caused 
more distress, than the doctrine that there is a mysterious sin 
which any one may ignorantly commit, and never escape the 
eternal wrath of an offended God. The miserable sufferers 
themselves never know what it is, or, if they imagine they 
do, are afraid to reveal their knowledge. One poor girl, 
whose anguish of mind was pitiable to witness, informed me, 
in answer to my inquiries, that it was "too horrible to men- 
tion." 

The choleric temperament is more frequently encountered 
in the inhabitants of the warmer portions of the temperate 
zone than in other localities, and it is more common among 
men than among women. 

Individuals of the choleric temperament should be spar- 
ing in the use of alcoholic liquors and of stimulating articles 
of food ; they should exercise freely, be especially careful to 
maintain the digestive organs in a healthy condition, and, 
above all things, keep the emotions in subjection to the intel- 
lect. A neglect of this last injunction may of itself induce 
serious bodily or mental disease. 

The Nervous Temperament. — In this temperament the mani- 
festations of nervous energy are markedly prominent, and 
give peculiar impress to the whole body and mind. The 
countenance is usually pale, and the features thin and sharp ; 
the pulse is quick, small, and frequent, though not weak; 
the respiration active ; the chest and muscular system are 
generally not largely developed ; the skin is dry and rough ; 
and the digestive functions are performed irregularly. The 
urine is usually copious, and of pale color. 

In consequence of the comparative weakness of the mus- 
cles, persons of this temperament easily become fatigued; 
though, owing to the activity of the nervous system, they 
quickly rally. 

Prompt to form opinions and to arrive at conclusions, the 
subjects of the nervous temperament are not remarkable for 
stability of purpose. Their intellectual operations are rapid 



70 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

and brilliant, bnt, at the same time, not often persistent. 
Variety is constantly sought for ; and the mental efforts, like 
the physical, are, as it were, spasmodic, full of energy while 
they last, but soon yielding to others. 

Women were formerly much more frequently the subjects 
of this temperament than men, but, owing to the constant 
effort to get rich manifested by the male sex in recent times, 
and the consequent extreme development of the emotional 
system, and of certain faculties of the intellect, it is now far 
more common with them. Indeed, I am not sure but that in 
civilized communities, especially in the large cities of the 
United States, it has not become the predominating tempera- 
ment. The man who day after day is kept upon a mental 
rack by that most harassing of all the emotions — anxiety — will 
inevitably undergo such psychical and bodily changes as will 
change him from any other original temperament to the one 
under notice. Of all the temperaments, it is particularly easy 
to be acquired. It is the outcome of civilization and refine- 
ment, and, probably, but for these agencies, would never have 
arisen. Among barbarous nations it is almost unknown, and 
savages never exhibit it ; but it is common enough in London, 
Paris, and New York, and in men who, if they had lived a 
hundred years ago, would have been as phlegmatic as the 
most typical Dutchman. 

Voltaire and Frederick the Great, of Prussia, are notable 
examples of the nervous temperament. John Randolph, per- 
haps, affords the most remarkable example of it among dis- 
tinguished Americans. 

The diseases which are most apt to occur among individu- 
als of the nervous temperament are those which concern the 
nervous system. Thus, we have the various forms of neural- 
gia, certain affections of the spinal cord, hysteria in all its pro- 
tean varieties, chorea, catalepsy, ecstasy, and insanity of all 
types. In fact, the nervous temperament itself is, if strongly 
developed, almost a pathological condition. The sensibility 
is so acute, the capability for receiving mental impressions so 
decided, and the system is so readily thrown into disorder 
from slight causes, that the temperament in question may 
often be considered as the first manifestation of disease. In- 
deed, it frequently lapses almost insensibly into the condition 
which Whytt l described many years ago, and which has re- 

1 " Observations on the Nature, Causes, and Cure of those Disorders which 



TEMPERAMENT. 71 

cently been very fully considered under the name of " Nervo- 
sisme" by Bouchut. 1 

Persons of the nervous temperament are very subject to 
diseases which exist only in their imagination, or which, being 
slight, are exaggerated by the constant habit of introspection 
in which they indulge. They are thus very frequently ren- 
dered insensible by the morbid attention they give to symp- 
toms which are of no consequence, and which are often by no 
means abnormal. 

The peculiar exaggeration of the nervous temperament to 
which I have alluded as the insane temperament, is really a 
morbid condition, and will be more appropriately considered 
farther on. 

As has been said, it rarely happens that the temperaments 
are so clearly marked that any individual can be said to 
possess the traits of one without being endowed with some 
of the attributes of another. Thus, there are the sanguineo- 
lymphatic, the sanguineo- choleric, the sanguineo-nervous, and 
so on. Each of these conjoins in itself the manifestations of 
the temperaments of which it is composed, in an equal or 
nearly equal degree, or the traits of one may very decidedly 
predominate, in which case it is named accordingly. 

In addition, there are certain conditions which are degen- 
erations of the temperaments. Thus, there are the plethoric 
state, formed on the sanguineous, in which there is an abnormal 
development of the circulatory system ; the obese, on the lym- 
phatic, leading to the excessive formation of adipose tissue ; 
and the melancholic, on the choleric, in which there are ex- 
treme activity of the liver and a consequent tendency to dis- 
ease of the abdominal viscera. These may properly be con- 
sidered as positive diseases, and, as such, calling for medical 
intervention. 

have been commonly called Nervous, Hypochondriac, or Hysteric," third edi- 
tion, Edinburgh, 1767. 

1 " De l'etat nerveux, aigu et chronique, ou nervosisme," Paris, 1860. 



72 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

CHAPTER IX. 

CONSTITUTION. 

By constitution we understand the general condition of the 
system which results from the permanent state of the organs 
of the body, and the consequent degree of perfection of their 
action. A person may, therefore, have either a good or a bad 
constitution, according as the several organs of the body are 
of normal or abnormal structure, without or with a tendency 
to derangement from slight causes, and working properly and 
in harmony with each other, or acting imperfectly and without 
co-ordination of functions. In the first case, the vitality of 
the body, the capability of resisting morbific influences, and of 
recuperation, are greater than in the last ; the functions are 
performed with energy, the tissues are healthy, and, as a 
consequence, disorder and disease are not so liable to occur. 

On the contrary, persons with weak constitutions are prone 
to disease upon slight exposure to the operation of causes 
capable of inducing pathological disturbance. The circu- 
lation is weak and languid, and in the extremities, conse- 
quently, the temperature is not kept up to the normal stand- 
ard. Cold hands and feet, even in warm weather, are therefore 
a subject of constant complaint. Such individuals suffer se- 
verely from attacks of disease which persons of strong consti- 
tution would endure with scarcely a feeling of discomfort, 
and recuperate slowly, and often with frequent relapses. 
Moreover, they are attacked when the others escape. 

It is very much the same with a man as with an artificial 
machine. If the latter is well made, of good material, the 
several parts strongly put together, and working in harmony 
with each other, it will resist hard usage better, and do more 
work, than will the machine which is made of bad materials, 
in which the different parts are not well proportioned, and 
which are constructed without a due regard to the work they 
have to perform. 

Constitution differs from temperament, with which it has 
sometimes been confounded, in this, that while the latter refers 
to specific and well-defined differences, due to the particular 
manner in which certain vital processes react on the mind, the 
former is more general, and relates to the original structure 
and integrity of the organs and tissues of the body. An in- 



CONSTITUTION". 73 

dividual may possess any temperament conjoined with a good, 
bad, or indifferent constitution. Constitutions differ from 
each other only in degree of perfection, while the differences 
between temperaments are peculiar and radical. 

A weak constitution is, to a certain extent, capable of being 
strengthened by proper hygienic measures. A child born in 
poverty, and reared under circumstances unfavorable to the 
full development of the organs of the body, such as insuffi- 
cient food, clothing, light, and fresh air, may, if the condi- 
tions are changed at a sufficiently early period, develop into 
an adult of good constitution. Even at a late period of life 
much may be done by the employment of sanitary means to 
strengthen a constitution originally weak. 

The evidences of a feeble constitution are generally suffi- 
ciently clear to even superficial observation. The heart, the 
lungs, and the nervous system are found to be endowed with 
less than the normal amount of power, and, consequently, the 
functions appertaining to these organs are imperfectly per- 
formed. The chest is narrow and flat, the muscles flabby and 
weak, and the whole system is wanting in tone. 

The factor of constitution is equally powerful with the 
mind as with the body. Persons whose physical organization 
is below the normal standard are incapable of long-sustained 
or intense intellectual action, although the quality of mind 
produced, dependent as it is on the cerebral structure, may 
be good. The reason of this is that, if, for instance, the indi- 
vidual has naturally a weak digestive system, one liable to 
get out of order from those slight exciting causes which no 
one can altogether avoid, he is incapable of supplying the 
brain with the nutritive material which it requires to compen- 
sate for the waste caused by its action. Hence, the organ 
easily gets fatigued. . Besides, earnest and well - directed 
brain- work is impossible if the individual is constantly dis- 
turbed by uneasy or painful sensations in his abdomen, or in 
any other part of his body. The attention which is neces- 
sary for thought is diverted from the subject under consid- 
eration to the place where the pain is felt, and hence the 
process of reasoning is weak, or is altogether interrupted. 
Mens sana in corpore sano is almost a necessary relation. 

A naturally strong constitution may be weakened by ex- 
cesses or a neglect of the rules of health. The intemperate 
use of alcohol, inordinate sexual indulgence, long-continued 



74 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

exposure to the action of causes capable of depressing the 
vital powers, and frequent attacks of disease, will break down 
the strongest constitution. This is especially seen in the 
military service. Men originally well constituted and robust, 
subjected, often without the least attention being paid to their 
sanitary requirements, to the hardships incident to army life 
— exposure to all kinds of weather, loss of sleep, want of suf- 
ficiently nutritious food and of warm clothing, the absence of 
proper shelter — fall from the normal standard of health, and 
remain broken down for the rest of their lives. Tissues which 
were in the first place capable of performing their office in 
the economy lose this power in a measurable degree, and the 
whole organism becomes enfeebled and more susceptible to 
morbific influences. 

And what is true of the body % is equally so of the mind. 
A person with a brain originally well constituted may, by its 
injudicious use, not only lessen its mental power, but may 
make it the seat of such organic disease as will reduce him to 
a state of imbecility. I have seen many individuals who, by 
working their brain to an extent beyond that which the 
organ was capable of legitimately accomplishing, could not 
concentrate the mind for five minutes on the simplest matters 
without causing headache and mental confusion. 

Persons of strong constitutions are not so liable to insanity 
in any form as those of weak ones. The protective and resist- 
ing power of the former is exerted as well upon the brain as 
upon the other organs of the body. Should such an individ- 
ual, however, become insane, the probability of recovery is 
much greater than in another of feeble organization. 

It is in early childhood that most can be done to modify 
original defects of constitution. Weak and sickly children 
require the utmost care relative to their food, clothing, and 
physical and mental exercise. A strong meat diet, or, at 
least, an abundance of milk, eggs, or other animal food, is 
absolutely necessary when it is desirable to improve the tone 
of the system. Much injury is often done to children by con- 
fining them, as is often done, to a vegetable diet and milk and 
water. Such children generally remain weak and puny, and, 
if they live, become adults of feeble constitution. Many, 
too, are stunted in mind by overtasking their as yet unde- 
veloped brains. The process of hardening, as it is called, 
whether applied to mind or body, is one which, if injudiciously 



HEREDITARY TENDENCY. 75 

used without reference to the physical or mental powers of 
the child, is fraught with danger to the subject upon whom 
it is tried. 



CHAPTER X. 

HEREDITARY TENDENCY. 

The hereditary transmission of peculiarities of form, mental 
character, manner, idiosyncrasies, habits, and proclivity to dis- 
ease, is no longer a matter of doubt with those best qualified 
to form an opinion on the subject. In fact, to this tendency 
of like to beget like we owe the perpetuation of the different 
species of animals and plants, as well as the great number of 
varieties produced by the will of man, or by combinations of 
circumstances. 

We see on every side numerous instances of the existence 
of the law to which reference is made. The different varieties 
of the dog, of the ox, and other domestic animals, the several 
kinds of roses, apples, strawberries, and other plants, are all 
the results of hereditary transmission. 

Resemblances in features to parents are extremely com- 
mon in the progeny. A child looks like its father, its mother, 
or, perhaps, some collateral relation. The hereditary upper 
lip of the members of the house of Hapsburg is an example 
of this fact, and others must be familiar to most persons. 
In the lower animals the same law applies with equal, if not 
greater, force. A whole litter of pups, for instance, will be 
marked like the father or mother, or, perhaps, some like one, 
and the remainder like the other. 

Certain qualities can also be transmitted. Thus, the setter 
and pointer possess their peculiar accomplishments by hered- 
itary descent from ancestors which were taught to indicate 
the presence of game by the actions they employ. I knew a 
lady who could always tell twenty-four hours in advance that 
rain or snow was at hand. She felt a cold sensation in both 
ears. Her mother had the same faculty, as has also her daugh- 
ter. I have already given instances of the hereditary trans- 
mission of habits, but the following, which has recently come 
to my knowledge, will not be out of place : 

A lady informed me that her grandmother, who had some 



76 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

affection of the right eye that rendered the accession of light 
to it unpleasant, always worked at her embroidery or sewing 
with that eye closed. Her daughter had no ocular disorder, 
but, in doing any kind of needle-work, always shut the sight 
eye. Her daughter, my informant, has a similar habit, which 
she acquired when quite young, although constant efforts were 
made to break her of the " trick." She came to me for advice 
relative to her little girl, eight years old, who, when given 
some sewing to do a few days previously, had at once closed 
the right eye on beginning her task. Here we have a habit 
descending through four generations. Instances like this 
almost lead us to the belief that it would be entirely prac- 
ticable to form a variety of the human race the women of 
which would always sew with the right eye closed. 

Certain natural deformities or organic deviations are like- 
wise sometimes indubitably transmitted to the progeny. It 
is, therefore, by no means rare to find that the immediate an- 
cestors of individuals with superfluous fingers or toes, club- 
feet, or hare-lip, were similarly affected. 

Accidental anomalies or mutilations are also the subjects of 
hereditary transmission. Thus, Grognier * states that he has 
observed that the colts whose ancestors had for many ascend- 
ing generations been branded on a particular part of the body 
were born with marks corresponding in situation and appear- 
ance to those made by the hot iron. According to Blumen- 
bach, 3 a man had the little finger of his right hand badly in- 
jured, so that it became crooked. He subsequently had sev- 
eral sons, each of whom had the little finger of the right hand 
twisted like that of their father. 

Among the Esquimaux and Kamtchatkans it is the custom 
to cut off the tails of the dogs used in drawing the sledges. It 
is frequently the case that the puppies come into the world 
without a tail, or with the appendage very much abbreviated. 3 
Other instances of the same kind are cited by Lucas. 

But the most important part of the subject of hereditary 
influence which we have at present to consider is in relation 
to the transmission of diseases or predispositions to disease. 

1 Cited by Lucas, " Traite philosophique et physiologique de l'h6redite natu- 
relle," Paris, 1850, t. ii, p. 492. 

a Blumenbaeh, cited from Treviranus by Lucas, op. cit., p. 493. 

3 Langsdorff, cited by Lucas, op. cit., p. 493 ; also Quatrefages, cited by Kibot, 
" L'beredite psycbologique," Paris, 1882, p. 9. 



HEREDITARY TENDENCY. 77 

Like the transmission of the physical and mental qualities, 
the transfer of pathological tendencies from parents to off- 
spring must be accepted as a fact amply capable of demon- 
stration, but not susceptible of explanation. When we say 
that the seminal fluid, being derived from the blood, must 
possess the abnormal impress of the blood, we assert a propo- 
sition just as difficult of demonstration, and in no way an elu- 
cidation of the question. Besides, admitting that the seminal 
fluid of a phthisical person may contain, in an inappreciable 
form, the germs of tubercles, we could not explain why the 
offspring of such a person should remain all their lives free 
from phthisis, and the Jiext^ generation exhibit unequivocal 
evidence of the presence of tubercular deposits in the lungs. 
That the tendency to certain diseases is derived from the semi- 
nal fluid of the male, and in an equal or perhaps greater 
degree from the ovaries of the female, does not admit of a rea- 
sonable doubt ; but that there are other agencies at work ca- 
pable of influencing the child while yet unborn is quite as cer- 
tain. And this fact demands that a distinction shall be made 
between those diseases or other peculiarities which are con- 
nate and those which are purely hereditary. By a connate 
disease we understand one which the child possesses when 
born, not necessarily the result of any similar taint or impres- 
sion received from the system, either of the father or mother, 
but due to accidents or mental influences operating through 
the mother. For instance, a child may be born idiotic, not 
because either of the parents or other ancestors were similarly 
affected, but through the influence of some severe mental or 
physical shock received by the mother during her pregnancy. 
Another may be epileptic — when neither parent has ever been 
subject to epilepsy or any other disease of the nervous system 
— if one or other is intoxicated at the time of the intercourse 
resulting in conception. 

Such cases are, of course, not due to hereditary transmis- 
sion, for a disease cannot be communicated hereditarily which 
has not affected either of the parents or any other ancestor. 

Many interesting cases showing the influence of the mater- 
nal mind over the offspring before birth are cited by M. de 
Frariere x and the elder Seguin.' There is no doubt that idiocy, 

1 " Education anterieure. Influences maternelles pendant la gestation," Paris, 
1862. 

8 "Idiocy and its Treatment by the Physiological Method," New York, 1866. 



78 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

and other forms of disorder of the mind, may be indnced in 
the nnborn infant by strong emotional or other mental dis- 
turbance in the mother. 

A singular fact connected with the transmission of diseases, 
and also of deformities or resemblances, is that a whole gen- 
eration, or one or more members of it, are passed over, the dis- 
ease or other peculiarity appearing in the next ; or a child, 
instead of resembling either of his parents, has the appearance 
or peculiarities of one of his grandparents. This is called 
atavism. Its existence was known to the ancients. Aristotle, 
Galen, Pliny, and Plutarch refer to it, and the latter gives the 
case of a Greek woman who, having given birth to a black 
child, was tried for adultery, when it was discovered that she 
was the fourth generation of an Ethiopian. 

A distinction must be made between those diseases which, 
though hereditary, are congenital, and those which appear 
after a lapse of time, often considerable. Thus, for example, 
cataract, deafness, and several kinds of deformities, belong to 
the first-named class, but the great majority belong to the 
second, and arise as a consequence of the predisposition which 
has been transmitted. They are, thus, of very great impor- 
tance to the physician, because, as the tendency only is con- 
veyed, and this may not be very strong, it is altogether possi- 
ble frequently to prevent the predisposition being developed 
into positive disease. 

Thus, Voltaire * says : 

"I have almost with my own eyes seen a suicide whose 
case deserves the attention of physicians. A man of serious 
turn of mind, of mature age, and of irreproachable conduct, 
free from strong passions and above want, killed himself on 
the 17th of October, 1769, and left a written explanation of 
his act, addressed to the council of the city in which he was 
born. This it was thought best not to publish, for fear of 
encouraging others to quit a life of which so much evil is 
spoken. In all this there was nothing astonishing ; such 
cases are met with every day. But the sequel is more re- 
markable. His father and his brother had each committed 
suicide at the same age as himself. What hidden disposition 
of the organs, what sympathy, what combination of physical 
laws, caused the father and his two children to perish by their 
own hands, by the same method, and at the same age % Was 

1 " Dictioimaire philosophique," art. "Caton du suicide. 1 ' 



HEREDITARY TENDENCY. 79 

it a disease which had long previously been developed in 
their family, as parents and children are often seen to die of 
the small-pox, of pneumonia, or of some other disease % Three 
or four generations become blind, or deaf, or gouty, or scrofu- 
lous, at a certain age." Many similar cases have been cited 
by writers on the subject. The following is within my own 
knowledge : 

A gentleman, well to do in the world, but with a slight 
hereditary tendency to insanity, killed himself in the thirty- 
fifth year of his age by cutting ETs throat while in a warm 
bath. No cause could be assigned for the act. He had two 
sons and a daughter — all under age at the time of his death. 
The family separated, the daughter marrying. On arriving 
at the age of thirty-five, the eldest son cut his throat while in 
a warm bath, but was rescued ere life was extinct. At about 
the same age the second son succeeded in killing himself in 
the same way. The daughter, in her thirty -fourth year, was 
found dead in a bath-tub with her throat cut. Her son, at the 
age of twenty-seven, attempted to kill himself by cutting his 
throat while in a bath at his hotel in Paris, but did not suc- 
ceed. Subsequently, at the age of thirty, he made a similar 
unsuccessful attempt, but was again saved. A year afterward 
he was found in his bath by his servant with his throat cut 
from ear to ear. 

A very striking physiological fact is not without influence 
upon the laws of hereditary transmission. It is well known 
that the children of a woman by her second husband may 
resemble physically and mentally her first husband, provided 
she has had children by the latter. The blood of the foetus 
in utero circulates through the system of the mother. This 
blood has the impress of the father derived through the semi- 
nal fluid. It must, therefore, in a greater or less degree, exert 
an influence upon the organism of the mother. Perhaps this 
is in accordance with Darwin's provisional theory of pangene- 
sis ; but, whether or not, the fact exists. Now the husband^: 
dying, and the mother marrying again and having children, is 
the medium for transmitting to this second set of offspring the 
peculiarities of mind and person which she has received from 
her first husband through his children before they were born. 
In this way the diseases of a man may be transmitted to chil- 
dren which are not his. In the lower animals, instances of this 
species of transmission are far from being rare. A bitch will 



80 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

have a litter one half of which will resemble in their markings 
their progenitor, and the other half a dog by which she has 
previously had offspring. In the horse the like fact has been 
noticed, and it doubtless prevails to some extent throughout 
the entire vertebrate class of animals. Breeders of domestic 
animals are fuUy aware of its existence, and are careful that 
the females used for raising fine stock are not approached 
by males of bad qualities. 

That insanity is often transmitted by hereditary influence 
is a fact scarcely requiring discussion, but for the circum- 
stance that it has been recently denied by certain medical wit- 
nesses in a criminal trial that such was ever its origin. Nev- 
ertheless, these gentlemen were by no means the first to ad- 
vance the hypothesis that insanity is Hmited in its influence 
to the individual in whom it first appears, and that it never 
has heredity for its cause. Its author is Heinroth. 1 He says : 

" Insanity is the loss of moral Hberty ; it never depends 
on a physical cause ; it is not a disease of the body, but of 
the mind ; it is a sin. It is not, and it cannot be, hereditary, 
for the thinking ego, the soul, is not hereditary. The only 
things transmitted by generation are temperament and consti- 
tution, against which he who has insane ancestors should pro- 
tect himself if he would escape lunacy. The man who has, 
during his whole life, before his eyes and in his heart, the 
image of God, has no fear of ever losing his reason. It is as 
clear as the light of day that the torments of those wretches 
called bewitched and possessed are the consequences of the 
development of remorse of conscience. Man has not only re- 
ceived reason ; he has, besides, a certain moral power which 
cannot be conquered by any physical power, and which never 
succumbs except under the weight of its own sins." 

Commenting on this extraordinary system of mental pa- 
thology, M. Lelut 3 says : 

"This passage from M. Heinroth contains as many errors 
as it does phrases. To say that a man who has all his life 
kept the image of God in his heart will never become insane, 
is to refuse to recognize the innumerable cases of insanity de- 

1 See the German translation of Esquirol's works by Hille, of Dresden, with 
notes by Heinroth, Leipsic, 1837, cited by Lelut, "Du traitement moral de la 
folie," Paris, 1840, p. 146; and also by Lemoine, "L'aliene devant la philoso- 
phie, la morale et la societe," Paris, 1865, p. 55 ; also by Eibot, op. cit., p. 140; 
also by Lucas, op. cit., t. ii, p. 756. *'Op. cit, p. 147. 



HEREDITAKY TENDENCY. 81 

veloped by superstition and an ascetic life ; to impute the tor- 
ments of the bewitched and the possessed of the devil to 
remorse of conscience, is to calumniate those unfortunate per- 
sons who often have only exaggerated their sins, or have 
even accused themselves of crimes they never committed ; to 
affirm that man has a moral power which cannot be overcome 
by any physical force, is to ignore the influence of wounds of 
the head, the ingestion of certain poisonous substances, in- 
flammation of the meninges, etc., in the production of insan- 
ity. (_ To refuse to admit that insanity may be transmitted by 
the process of generation is to refuse to accept the evidence 
of that which we see every day." 

Lucas * asserts that Rush expresses a doubt in regard to 
the hereditary transmission of insanity, and the witnesses in 
question may have entertained a like opinion relative to his 
views. But this is an error, for the great American physician 
is emphatic enough when he declares his opinion in the affirm- 
ative, and adduces numerous examples in its support. He 
says : ' 

"A peculiar and hereditary sameness of organization of 
the nerves, brain, and blood-vessels, on which I said formerly 
the predisposition to madness depended, sometimes pervades 
whole families, and renders them liable to this disease from a 
transient or feeble operation of its causes." 

He then states that application was made on one day for 
the admission of three members of the same family into the 
Pennsylvania Hospital, and that he had attended two ladies, 
one of whom was the fourth, and the other the ninth, of their 
respective families who had been affected with insanity in 
two generations. Moreover, he declares that, when there is a 
hereditary predisposition to mental aberration, it is induced 
by feebler exciting causes than when no such tendency exists. 
And, again, that it generally attacks in those stages of life in 
which it has appeared in the pa tient's ance stors, and that 
children born previously to the attack of madness in their 
parents are less liable to inherit it than those who are born 
subsequently. 

Without entering at this time into the full consideration 
of the question, I will adduce the authority of a few of the 

1 Op. cit, t. ii, p. 756. 

3 "Medical Inquiries and Observations upon the Diseases of the Mind,' 1 
fourth edition, Philadelphia, 1830, p. 46. 



82 PHYSIOLOGY AKD PATHOLOGY OF THE MIND. 

most eminent writers on mental derangement, premising that, 
with the exception of Heinroth, already cited, and the modi- 
fied view of Lordat, ' I would not know where to find a single 
negative opinion from any writer on psychological medicine 
who had received a medical education. Esquirol a says : 

" Hereditary influence is the most ordinary predisposing 
cause of insanity, especially with the rich. . . . Insanity is 
more frequently transmitted by the mothers than by the 
fathers." 

Burrows 3 states that : 

"There certainly is no physical error in accounting insan- 
ity hereditary. Had the knowledge of this fact merely led 
to a closer inquiry respecting those with whom a connubial 
union is contemplated, it would be a commendable foresight, 
often conducing to the preservation of domestic bliss now too 
frequently interrupted by the development of this dreadful 
affliction in the object perhaps of our tenderest affections." 

Griesinger * says : 

" Statistical investigations strengthen very remarkably the 
opinion generally held by physicians and the laity, that in 
the greater number of cases of insanity an hereditary predis- 
position lies at the bottom of the malady ; and I believe that 
we might, without hesitation, affirm that there is really no 
circumstance more powerful than this." 

Leidesdorf, 5 in speaking of the hereditary character of 
many cases of insanity, says : 

"All alienists have established the importance of this 
cause, to which an average of one quarter of the cases of in- 
sanity is due, though individual statements on this point 
differ greatly. ^Marce goes so far as to assert that in nine 
tenths of all the cases of insanity hereditary antecedents will 
be found." 

Luys, 6 under the heading of "hereditary cerebral states," 
says : 

1 " Les lois de l'Mredite physiologique sont-elles les memes chez les betes et 
chez Thomme ? " Montpellier, 1842, p. 19. 

2 "Des maladies rnentales," Paris, 1838, t. i, p. 33. 

3 " An Inquiry into Certain Errors relative to Insanity, and their Conse- 
quences, Moral and Physical," London, 1820, p. 9. 

4 " Mental Pathology and Therapeutics," Sydenham Society Translation, p. 
150. 

6 " Lehrbuch der psychischen Krankheiten," Erlangen, 1865, p. 128. 

6 " Traits clinique et pratique des maladies rnentales," Paris, 1881, p. 214. 



HEREDITARY TENDENCY. 83 

" Heredity governs all the phenomena of mental pathology 
with the same results and the same energy as we see it con- 
trol moral and physical resemblances in the offspring. 

"The individual who comes into the world is not an iso- 
lated being separated from his kindred. He is one link in a 
long chain which is unrolled by time, and of which the first 
links are lost in the past. He is bound to those who follow 
him and to the atavic influences which he possesses ; he 
serves for their temporary resting-place, and he transmits 
them to his descendants. If he comes from a race well-en- 
dowed and well-formed, he possesses the characters of organi- 
zation which his ancestors have given him. He is ready for 
the combat of life, and to pursue his way by his own virtues 
and energies. 

' ' But inversely, if he springs from a stock which is already 
marked with a hereditary blemish, and in which the devel- 
opment of the nervous system is incomplete, he comes into 
existence with a badly balanced organization ; and his natural 
defects, existing as germs, and in a measure latent, are ready 
to be developed when some accidental cause arises to start 
them into activity." 

One other authority, and I am done with this question for 
the present. All admit the ability and knowledge with which 
the late Dr. Ray discussed all points connected with insanity. 
Relative to heredity, he says : l 

" The course of our inquiry, then, leads us to this conclu- 
sion — that in the production of insanity there is generally the 
concurrence of two classes of agencies, one consisting in some 
congenital imperfection of the brain, and the other in acciden- 
tal outward events. I do not say that mental disease is never 
produced by the latter class of cases exclusively. The pres- 
ent limited state of our knowledge forbids so sweeping a con- 
clusion. Cases sometimes occur where the closest investiga- 
tion discloses, apparently, no cause of cerebral disorder within 
the patient himself. There is good reason to believe that the 
number of such cases would be lessened by a deeper insight 
into the inner life, and a minuter knowledge of those organic 
movements which lead to disease. We know that, even in 
those cases in which, to all appearance, the casual incident 
was most competent of itself to produce the disease, the con- 
stitutional infirmity may be often discovered. Drunkenness, 
1 " Contributions to Mental Pathology," Boston, 1873, p. 45. 



84 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

epilepsy, blows on the head, sunstroke, would seem capable, 
if anything outward could, of producing insanity ; but, as a 
matter of fact, we find not unfrequently behind these casual 
events, firmly seated in the inmost constitution of the brain, 
the hereditary infirmity. Can we believe that it took no part 
in the morbid process % " 

If it be alleged that the disease insanity is not trans- 
mitted, but only the tendency to the disease, the same might 
be alleged of every other morbid condition regarded as he- 
reditary, except those existing at the time of birth, in the 
parents and offspring. 

Phthisis, gout, progressive muscular atrophy, and other 
indubitable hereditary affections, would from that point of 
view be non-hereditary. Besides, how would it be known, in 
the young infant, whether insanity existed at birth or not \ 
Where there is so little mind as the new-born child possesses, 
the manifestations of insanity must be so slight as to escape 
our observation. Not including cases of idiocy, there is, how- 
ever, abundant evidence to show that children do occasionally 
exhibit some of the most intense phases of insanity at very 
early periods of their lives. Komberg 1 has seen the case of a 
child, six years of age, in which there was a blind impulse to 
destroy everything upon which it could lay its hands. It 
rushed through the street with a knife in its hand, and was 
restrained with difficulty. Griesinger 2 states that children 
of three to four years of age often have attacks of crying, of 
wild restlessness, striking, biting, and endeavoring to destroy, 
which last only for a time, and which ought to be regarded as 
true mania. 

Dr. Rush 3 saw a case of insanity in a boy of seven years 
of age, and subsequently one in a child two years, that had 
been affected with cholera infantum, and another in a child 
of the same age, that was "affected with internal dropsy of 
the brain." u They both discovered the countenance of mad- 
ness, and they both attempted to bite, first their mothers and 
afterward their own flesh." 

Insanity, as a rule, makes its appearance, when hereditary, 
at the period of life in which the mind is most active ; and 
often the inherent condition is so strong that it develops into 
more intense forms of mental derangement upon exceedingly 

1 "Deutsche Klinik," 1851, p. 178. 
3 Op. cit., p. 142. 3 Op. cit., p. 55. 



HEREDITARY TENDENCY. 85 

slight cause, or even, so far as can be perceived, spontaneously. 
It cannot, in such cases, be prevented by any means we may 
employ. 

It is a peculiarity of nervous affections that they are not 
necessarily transmitted to descendants in the same form in 
which they appear in the ancestors. Thus, the latter may 
have epilepsy and the progeny neuralgia, migraine, or some 
variety of mental alienation, or the reverse may occur. 
Neither when insanity itself is clearly due to hereditary in- 
fluence is it always the case that a like type of disease is 
transmitted. The ancestors, for instance, may have had gen- 
eral paralysis, and the descendants will exhibit the several 
forms of mania or melancholia. 

A discussion of the subject of hereditary influence would 
manifestly be incomplete without reference to that of consan- 
guinity, in regard to which there is, I think, a good deal of 
misunderstanding. 

In the early history of mankind, marriages among blood 
relations were common. The Persians, Tartars, Scythians, 
Medes, Phoenicians, Egyptians, and Peruvians, not only mar- 
ried their sisters, but their daughters and their mothers. In- 
stances of such marriages among members of the royal fami- 
lies of antiquity are well known. 

The laws of the ancient Germans allowed consanguineous 
marriages, as did also those of the Arabs up to the period of 
Mahomet, 1 and the Jews, notwithstanding the prohibitions of 
Moses, continued them up to the present day. All civilized 
nations allow them within certain degrees. In the State of 
New York, for instance, first cousins may marry, as may also 
uncle and niece, or aunt and nephew. The State of Kentucky, 
however, prohibits the marriage of first cousins, and of all 
nearer degrees of relationship. 

The dangers of consanguineous marriages have been pointed 
out by many authors. 

M. Killiet a contends that all such marriages are. in them- 
selves pernicious, and tend with great certainty to a lowering 
of the vital force. The effects he divides into two categories : 

1. Those which relate to the parents, under which head are : 

1 "La consanguinite et les effets de l'heredite," par V. La Perre Roo, Paris, 
1881, p. 4. 

a "Lettre sur Fiufluence de la consanguinite sur les produits du marriage," 
Bulletin de VAcademie de Medecine, t. xxi, p. 746. 



86 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

a. Failure of conception. 

b. Retardation of conception. 

c. Imperfect conception. 

2. Those which relate to the progeny : 

a. Imperfections of various kinds. 

b. Monstrosities. 

c. Imperfect physical and mental organization. 

d. Tendency to diseases of the nervous system, such as 
epilepsy, imbecility, idiocy, deaf -mutism, paralysis, and vari- 
ous cerebral affections. 

e. Tendency to strumous diseases. 

f. Tendency to die young. 

g. Tendency to succumb to diseases which others would 
easily resist. 

It is easy to see that BUliet has made several tendencies 
out of one. Thus, the categories under b and c are manifestly 
included in a, and those under,/ and g in d and e. 

After a full consideration of all that Rilliet has to advance, 
I feel bound to agree in the main with De Roo l in the opin- 
ion that common-sense teaches us that all these ills do not 
proceed from consanguineous marriages, and that it would be 
very difficult for Rilliet to prove the half of what he has 
advanced. 

Among the opponents of such marriages are Devajr, a Hel- 
liot, 3 and Boudin, 4 in France ; Mitchell, 5 in Great Britain ; and 
Bemis, 6 in the United States. It was mainly through the ex- 
ertions of the latter that the State of Kentucky enacted a law 
prohibiting the marriage of blood relations nearer than second 
cousins. 

It is undoubtedly true that consanguineous marriages often 
result in the birth of children who are malformed, idiotic, 
deaf-mutes, or who become in after years the subjects of epi- 
lepsy, insanity, and other affections of the nervous system. 

On the other hand, it is undoubtedly true that many such 
marriages take place, the results of which are as perfect in 

1 Op. cit., p. 9. 

2 "Du danger des marriages consanguines," Paris, 1862. 

3 " Contribution a l'etude de la consanguinite," Paris, 1875. 

4 " Dangers des unions consanguines," etc., Paris, 1862. 

6 " On the Influence of Blood Kelationships in Marriage," Memoirs of the 
Anthropological Society of London, vol. ii, 1866. 

6 "On the Evil Effects of Marriages of Consanguinity," North American 
Medico- Chirurgical Review, vol. i, 1857, p. 97. 



HEREDITAKY TENDENCY. 87 

every respect as could be desired. Dr. Bourgeois * wrote the 
history of his own family, which was the issue of a union in 
the third degree of consanguinity. During the ensuing one 
hundred and sixty years there were ninety-one marriages, of 
which sixteen were consanguineous. Of these latter, all were 
productive, and there was not a single case of malformation 
or other physical or mental disease in the offspring. 

Huth 3 cites from Dr. Thibault the case of a slave-dealer 
who died in the year 1849, at Widah, Dahomey, leaving be- 
hind him four hundred disconsolate widows, and about one 
hundred children. By order of the king, the whole of this 
family was interned in a particular part of the country, where 
reigned the most complete promiscuity. In 1863 there were 
children of the third generation, and Dr. Thibault, who veri- 
fied the fact himself, asserts that at that time, although all 
these people were born from all degrees of incestuous unions, 
there was not a single case of deaf-mutism, blindness, cre- 
tinism, or any congenital malformation. Huth cites many 
other instances of isolated communities intermarrying con- 
tinually without detriment to the offspring. 

The truth appears to be found in the fact that consan- 
guineous marriages are not in themselves productive of evil 
results, either to the parents or offspring ; and that the ill 
consequences are to be ascribed to the operation of the law of 
hereditary influence, which, of course, is doubled so far as 
the progeny is concerned. If it is absolutely certain that a 
family is free from all taint of any kind whatever, there is no 
physiological reason why a man should not marry any female 
relative, however near ; but, as that can never be positively 
assumed, it is better to prohibit such marriages down to, or 
even including, second cousins. There are few persons who 
cannot call to mind one or more consanguineous marriages 
which have resulted in idiocy, epilepsy, insanity, or other 
mental or nervous diseases in the children. I am quite sure 
that there is a greater tendency to the production of such 
affections than of any other, many striking examples of the 
fact having come under my observation. 

1 Cited by Ribot, " De Theredite," Paris, 1882. 

2 "The Marriage of Near Kin, 1 ' etc. London, 1875, p. 161. 



SS PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

CHAPTER XL 

AGE. 

Time, which exercises its influence even npon inorganic 
bodies, is immeasurably more powerful in its relations with 
organized beings. They spring into existence, increase, decay, 
and die according to the laws of their being. In some the 
cycle is completed in a few days, or even hours, in others, in 
a few years, and in others, again, not until centuries have 
elapsed. 

This is equally true of animals and vegetables. The moth 
of the silk- worm and certain cryptogamic plants measure the 
period of their existence by hours, while the crocodile, the 
elephant, and the oak count hundreds of years of life. 

King David fixed the length of human life at seventy 
years, with eighty as an exceptional limit. Flourens l believes, 
with Buflon, the natural life of man to be one hundred 
years, and adduces many ingenious arguments in support of 
his opinion. Instances are not wanting in which even this 
limit has been greatly exceeded. Thomas Parr, for instance, 
is said to have lived to the age of one hundred and fifty-two 
years, and then to have died from indigestion caused by over- 
eating at a feast given to him by Charles I. Harvey made a 
post-mortem examination of his body, and found all his vis- 
cera in normal condition. The cartilages of his ribs were not 
ossified. 

Mr. E. Ray Lankester a cites instances in which one hun- 
dred and nine and a hundred and eleven years have been 
reached, but doubts if there is any authenticated instance of 
more than one hundred and twenty years having been attained. 
He cites statistics which go to show that in civilized communi- 
ties the average duration of life is greater in females than in 
males. 

During life the fluids and tissues of the body are con- 
stantly undergoing change. New matter is deposited, and 
the old is renewed with ceaseless activity. The body may be 
regarded as a complex machine, in which the law that force 
is only generated by decomposition is fully carried out. 
Every motion of the body, every pulsation of the heart, every 

1 "De la long6vite humaine et de la quantity de vie sur la globe," Paris, 1856. 

2 " On Comparative Longevity in Man and the Lower Animals," London, 1870. 



AGE. 89 

thought which emanates from the brain, is accompanied by 
the destruction of a certain amount of tissue. So long as food 
is supplied in abundance, and the assimilative functions are 
not disordered, reparation proceeds as rapidly as decay, and 
life is the result ; but, should nutrition be arrested by any 
cause for any considerable period, new matter ceases to be 
formed, and the organs, worn out, act no longer, and death 
ensues. 

The animal body differs from any inorganic machine in 
the fact that it possesses the power of self -repair. In the 
steam-engine, for instance, the fuel which serves for the pro- 
duction of steam, and subsequently for the creation of force, 
can do nothing toward the repair of the parts which have 
become worn out by use. Day by day, through constant attri- 
tion and other causes, the engine becomes less perfect, and 
must be put in order by the workman. In the animal body, 
however, the material which serves for the production of force 
is the body itself, the substances taken as food being first 
assimilated, and converted into brain-substance, muscle-sub- 
stance, heart-substance, etc. 

The body is therefore undergoing continual change. The 
hair of to-day is not the hair of yesterday ; the muscle which 
extends the arm is not identically the same muscle after as 
before the action ; old material has been removed and new 
has been deposited to an equal extent ; and, though the weight 
and form, the chemical constitution, and histological characters 
are preserved, the identity has been lost. If, however, a mus- 
cle be detached from the recently dead body of an animal, 
accurately weighed, made to contract many times by a current 
of electricity, and then weighed again, it will be perceived to 
have lost appreciably a portion of its substance. 

So long as the processes of waste and repair exactly coun- 
terbalance each other, life continues. If it were possible so to 
adjust them to each other that neither would be in excess, 
there is no physiological reason why life, if protected against 
accidents, should not continue indefinitely. But this is not, 
with our present knowledge, possible ; decomposition even- 
tually predominates, and death from old age results. 

The life of man has been variously divided by different 
authors into artificial stages or periods, the limits of which are 
by no means accurately fixed. A natural division, which is 
based upon the physiological course of life, is not only more 



90 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

convenient, but is more correct. In accordance with this 
principle, therefore, I would divide the life of man into three 
periods : 1. The period of increase, in which the formation 
of tissues predominates over decay ; this stage extends from 
birth to about the twenty -fifth year, varying according to 
individual and sexual peculiarities ; 2. The period of matur- 
ity, in which the two processes counterbalance each other, 
extending from the twenty-fifth year, or thereabouts, to the 
thirty-fifth year ; 3. The period of decay, in which the tis- 
sues are not regenerated as rapidly and perfectly as they are 
broken down and excreted from the system, and reaching 
from the thirty -fifth year to the extreme limit of human life. 1 
Each of these stages is marked by strong peculiarities both 
of organization and action, and they exhibit immunities to 
some diseases and susceptibilities to others, which are only to 
be accounted for by a reference to the physiological condition 
by which each stage is characterized. 

The Period of Increase. — The average height of the human 
subject at birth is between eighteen and nineteen inches, and 
the weight about seven pounds. The bones are not yet com- 
pletely ossified, the muscles are soft, the skin thin and highly 
vascular, and the circulatory and nervous apparatus devel- 
oped to a much greater extent comparatively than at any other 
period of life. 

A great tendency exists during the first five years of the 
period of increase to diseases of the nervous system, and this 
is at its maximum during the first dentition. Convulsions due 
to irritation, and inflammation of the brain and its membranes 
are accordingly of common occurrence. As we have seen, 
insanity may exist at this time, and this either from heredi- 
tary transmission or arising from some accidental cause. In 
addition to the facts cited in the immediately preceding chap- 
ter, the following are worthy of notice : 

Guislain 2 states that he possesses in his notes several re- 
markable examples of infants who have become maniacs before 
the age of puberty. He has seen subjects only three or four 
years old, who up to that age had shown much intelligence 
and even a precocious development of the mental faculties, 

1 This division, which is as old as Aristotle, is preferable to any which haa 
been since devised. 

2 " Lecons orales sur les phrenopathies, ou traite theorique et pratique deo 
maladies mentales," Paris, 1880, t. i, p. 447. 



AGE. 91 

experience suddenly an entire change of character, becom- 
ing at first morose and then excited, violent, and exhibiting 
in their countenances the signs of intellectual derangement. 
This condition has lasted several months, and has then disap- 
peared, to be replaced by an apparently normal state. More- 
over, such instances have occurred in several infants of the 
same family, in which, nevertheless, insanity was not heredi- 
tary. 

Morel ! cites from his own experience the case of a girl ten 
and a half years old who, on being frightened, fell into con- 
vulsions, and immediately lost the faculty of speech. Her 
mental state was characterized by exacerbations of such a 
nature that it was necessary to confine her in an asylum, in 
which she was a constant source of trouble. She seemed 
never to be happy unless she was destroying everything which 
came into her hands, and tormenting the adult lunatics. 

In another case, which also came under his notice, the sub- 
ject, a boy five years of age, was suddenly frightened, lost 
the power of speech, and for three years that he was in an 
asylum exhibited constant turbulence and frequent maniacal 
exacerbations. 

Dr. Chatelain 3 reports a remarkable case of acute mania 
occurring in an infant four years and nine months old, who 
was frightened by a fire-engine. At first she had hallucina- 
tions of hearing and of sight, then, as the violence of the dis- 
ease increased, she was constantly in motion, gesticulated vio- 
lently, grew angry, struck at persons, wept, and wished to 
kill her relations. Finally, after several weeks, she became 
better, and probably entirely recovered. 

Several cases of insanity in youths of either sex have come 
under my observation, but only one in which the subject was 
of very tender age. This was a boy about six or seven years 
old, whom I saw in consultation with Dr. E. M. Hunt, of Me- 
tuchen, New Jersey. Frequently during the day he would 
experience attacks of acute maniacal excitement, during which 
he would bite, kick, and strike at all who came near him, and 
destroy everything within his power or reach. While the par- 
oxysm was on him he was in constant motion, running and 
dancing around the room, climbing over the tables and chairs, 
gesticulating violently, and shouting or talking incoherently 



1 u 



Traite" des maladies mentales," Paris, 1860, p. 101. 
2 Journal de Medicine Mentale, t. x, p. 322. 



92 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

at the top of his voice. There was some evidence to show 
that when an infant in arms he had received a fall, striking his 
head. The place was pointed out differently by his mother 
and grandmother, but, acting npon what I conceived was the 
better evidence, I determined to trephine him. The operation 
was performed with Dr. Hunt's assistance, the cranium being 
perforated at the right parietal eminence. No injury of the 
bone was found, but recovery took place immediately, and the 
patient is now, as I believe, a healthy and sane young man. 
It is a notable fact that insanity in young persons is very 
apt to take the form of mania with destructive tendencies. 
The patients exhibit strong propensities to kill or. torture 
animals, and to inflict wanton cruelties on their compan- 
ions. 

Strange as it may seem, suicide is by no means an un- 
known act with very young children. With youths, as we are 
constantly being informed by the newspapers of the day, it is 
more common. M. Durand-Fardel * found that of 25,760 sui- 
cides occurring in France in the ten years from 1835 to 1844, 
192 were in persons under sixteen years of age. Of these 
latter 1 was under five years, 2 between eight and nine years, 
2 between nine and ten years, and 6 between eleven and 
twelve years of age. 

Referring to these statistics, Brierre de Boismont 2 says : 

" We can understand suicide by infants when we read in 
the confessions of Saint Augustine that a child at the breast, 
when its nurse suckled another baby, went into a violent fit of 
anger at the sight, and almost had convulsions." 

According to the census ot 1880 there were in the United 
States, during the preceding ten years, 2 suicides by children 
between five and ten years of age ; 12 between ten and fifteen 
years ; 66 between fifteen and twenty years ; and 136 between 
twenty and twenty-five years. 

Montaigne 3 states that in his time there were many exam- 
ples of children committing suicide in order to escape from 
some slight inconvenience. 

And this is one of the chief characteristics of suicide when 
perpetrated by children — that it is generally for some notion 

1 " Etudes sur le suicide chez les enfants," Annales medico-psychologiques, 
Janvier, 1855. 

2 "Du suicide et de la folie suicide," Paris, 1856, p. 68. 

3 "Essais," liv. i, chap, xv, p. 293, Edition de Leftvre. 



AGE. 93 

which to the adult mind appears to be altogether inadequate, 
often ridiculously so. 

Esquirol x cites the case of a boy thirteen years old, who, 
for some trifling cause, hanged himself, leaving a statement 
in writing that he left his soul to Rousseau and his body to 
the earth ; and from Falret another, also a boy, twelve years 
of age, who hanged himself because a composition which he 
hoped would obtain the first place was only twelfth. The fol- 
lowing cases are reported by Dr. Forbes Winslow. 2 

Harriet Cooper, aged ten years and two months, upon 
being reproved for a trifling fault, went upstairs and hanged 
herself with a pair of cotton braces. Another, named Green, 
aged eleven, drowned herself from the fear of correction for a 
trifling fault. And he cites from Casper the statement of Dr. 
Schlegel that in Berlin between the years 1812 and 1821 no 
less than thirty- one children of twelve years of age and under 
committed suicide either because they were tired of existence 
or had suffered some trifling chastisement. 

Collineau 3 refers to the case of a boy ten or twelve years 
of age, who, on being sent back to college before his holiday 
was over, hanged himself, as he said in writing, to make Ms 
parents angry. 

Another, ten years old, on being reprimanded by her 
mother, answered : "If you torment me in this way, you will 
some day find me hanging to the bed-post " ; another of nine 
years actually threw herself out of the window to avoid a 
scolding for having broken a goblet ; and still another of only 
five years hanged himself to escape from the bad treatment of 
his mother. 

Cases like these might be cited by the dozen. The daily 
press makes them familiar to us all ; only to-day (August 
10th) the New York morning papers report the case of a boy 
aged fourteen, who, having broken a pane of glass in the shop 
in which he was employed, was told that he would have to 
replace it. Afterward he was sent out with a clock which 
had been repaired, and on which he was to collect a dollar. 
Then he hired a rowboat, went out on Jamaica Bay, and, an- 
choring at about three hundred yards from the shore, shot 

1 Op. cit., t. i, p. 289. 

2 "The Anatomy of Suicide," London, 1840, p. 269. 

3 "Du suicide chez les enfants," Journal de Medicine Mentale, t. viii, 1868, 
p. 417. 



94: PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

himself with a toy pistol. His dead body was found at the 
bottom of the boat. 

A short time ago a case went the rounds of the press of a 
boy of ten years who had hanged himself because as he said 
he was " tired of so much dressing and undressing." Surely 
there must be an innate abnormal brain-formation in such 
children, one that if they had lived to attain maturity would 
have caused infinite trouble to themselves and those around 
them. 

As the age of the individual advances, the body becomes 
more fully developed and is enabled better to resist disease. 
By the time puberty is attained, which in the United States 
is about the sixteenth year for boys and the fifteenth for girls, 
the tissues have acquired considerable solidity, the bones have 
become harder, though the epiphyses are not yet consolidated 
with the shafts, and the circulatory, respiratory, and digestive 
organs have, in a measure, lost the excessive sensibility by 
which they were characterized in infancy. 

The genital organs, which have hitherto exercised but little 
influence over the general system, now become capable of 
performing their functions. In the male the secretion of 
semen takes place, and in the female menstruation begins. 
The larynx, which in the infant is small and round, now be- 
comes lengthened, and in the male especially the voice assumes 
a more grave tone. 

The intellectual faculties have not been behindhand. The 
brain, though relatively smaller, has undergone consolidation 
and hardening of its substance, and has, in conjunction with 
the other organs of the system, lost to a material extent the 
peculiar sensibility to external impressions which belonged to 
it in early infancy, gaining in strength, in force, and in ca- 
pacity for improvement. 

The relation between the formative and destructive pro- 
cesses is more evenly balanced, and the body has nearly at- 
tained the period when growth ceases. This point is in males 
about the twenty-fifth year, and in females about a year 
earlier. 

Insanity in some one of its several forms, though not es- 
pecially common about the age of puberty, is nevertheless 
not infrequently encountered. Its more usual variety is mania, 
but it is sometimes met with as an affection mainly of the 
emotions, or as characterized by blind and unreasoning im- 



AGE. 95 

pulses to acts of deceit or violence. Fixed delusions are not 
a prominent feature, but, as Blandf ord * states, there are per- 
verted feelings, hatred of relations, wanton and indecent be- 
havior, cruelty and destructiveness, and hallucinations of the 
senses. 

Several cases of insanity occurring in young persons have 
come under my observation, and all were, with one excep- 
tion, of the types above described, presenting very much the 
general appearance of reasoning mania, to which attention will 
subsequently be fully directed. In one of these instances the 
patient, a young lady about fifteen years of age, had been 
for some two or more months affected with an impulse to 
torture and kill every animal which came under her notice. 
How it originated she could not precisely say, but was dis- 
posed to think that the first time she felt it was when witness- 
ing a cat playing with and finally killing a mouse. At once 
she procured several traps, all so constructed that the animals 
were captured alive. Then she would put some into a wash- 
basin, and, gradually turning on the hot water, would watch 
their struggles with the greatest pleasure till they were finally 
scalded to death. Others she placed in the trap on the top 
of a hot stove, enjoying their struggles in their frantic efforts 
to escape. And others again were deliberately cut to pieces 
with scissors. Upon one occasion she threw a whole litter of 
kittens into a bucket of boiling water. When the larger ani- 
mals were not available, she spent her time in catching and 
killing flies. She confessed to me that her great desire was 
to steal a baby and skin it alive, but that she was afraid to 
make the attempt lest she should be arrested and hanged for 
it. She was at the same time a teacher in a Sunday-school, and 
she declared that it was with the utmost difficulty she could 
refrain from enticing one of the younger pupils into a corn- 
field near which they passed on their way home from church 
and killing her. She had even gone so far as to put a piece 
of twine into her pocket, with which she designed strangling 
her victim, but the fear of the law had always prevented her. 

There were periods of remission in which she was a prey 
to the deepest feelings of remorse, and it was in one of these 
that she was brought to me by her father, a worthy gentle- 
man, who had endeavored to conceal his daughter's misfor- 
tune and to cure her by moral suasion. Not finding this suc- 

1 "Insanity and its Treatment," Edinburgh, 1871, p. 125. 



96 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

cessful, lie had called together a few friends, and together 
they had prayed for her recovery, also without favorable 
result. 

She reasoned with entire calmness about her misfortune, 
and with tears in her eyes and much lamentation regretted 
her inability to control the impulse which moved her, and 
which she was sure came from the devil. I attributed it, how- 
ever, to another cause, and, by regulating her menstrual func- 
tion, succeeded in a short time in restoring her to health. 
Such cases, however, more properly belong to the following 
chapter, on sex. Others of similar character will engage our 
attention in subsequent parts of this treatise. 

I am inclined to think that this disturbance of the moral 
and emotional faculties without marked aberration of the in- 
tellect, when occurring in young persons, is more common in 
girls than in boys. 

Later on, during the period from fifteen years of age to 
twenty -five, the tendency to insanity is still greater, the emo- 
tional system is more fully developed, and in both sexes love 
begins to play an important part in the promotion of mental 
disorders. The struggle for existence and position has begun, 
and the individual is sometimes slowly, sometimes rapidly, 
but always surely, taught that there are trouble and sorrow 
and exertion before him. To some this knowledge is more 
than the mind can bear. There are very few at this age and 
at this day who, according to my experience, injure themselves 
by intellectual exertion. Occasionally, however, the mind is 
overtasked, and a quasi insane condition is produced, which, 
if not promptly relieved, terminates in mental alienation. 
The struggle for position is by no means confined to adults. 
It exists with the boys and girls in our schools, counting- 
houses, and even in our workshops. Not long ago a young 
man, not over sixteen years of age, was brought to me in a 
high state of acute mania, induced by his efforts to excel in 
the work of copying letters ; and I was shortly afterward con- 
sulted in the case of another of like age, who had become 
melancholic and subject to the delusion that he had com- 
mitted the "unpardonable sin," the consequence of excessive 
application to his trade as a violin-maker. This is the ex- 
ceptional case to the rule of moral perversion only, to which 
allusion has just been made. 

The Period of Maturity.— Some authors consider that physio- 



AGE. 97 

logically there are but two periods in the life of man, that of 
increase and that of decline. Strictly speaking, this view may 
be the correct one, but there is a time when if there is any 
increase in development it is scarcely perceptible, and if any 
decline this is so gradually effected that it is inappreciable by 
any means at our disposal. 

This period may very properly therefore be regarded as 
that at which the formation and destruction of tissues are so 
nearly balanced that the body may be regarded as fully ma- 
ture. Tissue is not, as in the preceding stage, deposited faster 
than it is removed, but the wants of the system are exactly 
compensated by the deposit of new material to take the place 
of that removed as effete. 

At the beginning of this period, which ordinarily extends 
from the twenty-fifth to the thirty-fifth year of life, the epi- 
physes of the bones become firmly incorporated with the 
shafts, the flesh becomes hard and firm, and the physical 
strength is at its maximum. 

The mental faculties, though more strongly developed than 
in the former period, are not yet in their prime. This is a 
curious circumstance, and one which is at variance with our 
preconceived opinions. Some faculties of the intellect and 
some of the emotions are, perhaps, equal in force and activity 
to their development at any other period of life, but, as a 
whole, the mind is not possessed of the capacity, the strength, 
the endurance, or the power of concentration, which it has 
during the next period, when the physical powers have begun 
to decline. 

A little reflection reveals to us the reasons for this, which 
are two in number : 

1. The brain does not attain to its maximum degree of 
development at the same time as do the other viscera and the 
osseous and muscular system. So far as size is concerned, it 
probably does not, as the Brothers AYenzel contended, reach 
its maximum at the seventh year, but, as Dr. Boyd 1 has shown, 
it is very nearly as large at this period as it ever will be, and 
by the twentieth year it has attained to its full size. But, after 
this point is arrived at, it continues to gain in firmness of 
structure owing to the gradual loss of a portion of its water, 
and thus there is a comparative augmentation of brain-tissue, 
an increase of weight, going on far into the period of decline. 

1 Quoted by Thurnam, op. cit. 

T 



98 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

2. As the mind feeds on the impressions which reach the 
brain through the special senses, it has not had time by the 
end of the period of maturity, which is at the thirty -fifth 
year, to acquire all the information necessary for it to reach 
its greatest stage of development, which is during the next 
period. 

It is during the period of maturity that insanity is mosfr. 
common. Wealth and station have generally not yet been 
fully reached even by those most favorably situated for get- 
ting them, while, on the other hand, the contest has termi- 
nated disastrously for many who entered upon it with high 
hopes and expectations. These circumstances cannot fail to 
increase the wear and tear of brain, and, consequently, to 
augment the number of cases of mental alienation over those 
of either the preceding or the following period. 

Moreover, it is during this period that the cares of life are 
greatest in both sexes, through the necessity which exists for 
providing for a family not yet able to provide for itself. This 
alone is often a cause of insanity. 

The Period of Decline. — The period of decline is marked by 
as many striking characteristics as those which belong to the 
period of increase. After the body has remained at nearly 
a fixed point of development for a few years, varying from 
five to ten, a disposition is manifested to degeneration. The 
process of decay becomes more powerful than that concerned 
in the regeneration of tissues, and, in consequence, the body 
not only loses weight from the atrophy of its parts, but the 
functions are less perfectly performed. Thus, the action of 
the heart becomes weaker and less frequent, the respiration 
slower, the digestion feebler, the muscles thinner and more 
rigid, the skin shrunken, the joints stiff, the teeth fall out, 
the hair becomes gray, the arteries ossified, and the entire 
form loses its elasticity and becomes less erect than in adult 
age. The whole tendency of the body is toward consolidation. 
The generative function is greatly weakened or altogether lost 
in both sexes, and in the female the menses cease to flow. 

The organs of special sense, toward the latter portion of 
the period, also become involved in the process of degenera- 
tion. The eyes lose their brightness, and the sight grows dim , 
and presbyopic. The hearing diminishes in acuteness, the 
taste is blunted, and the sense of smell is almost, if not alto- 
gether, lost at a comparatively early period. 



AGE. 99 

In these changes the mind also participates, but not in 
an equal ratio to the changes going on in other parts of the 
body. Indeed there is, during the first ten or fifteen years of 
this period, an increase in the strength and powers of endur- 
ance of the mind, and quite often this process continues for 
several additional years. The judgment, owing to the experi- 
ence which the individual has obtained in the affairs of life, 
becomes riper and more unerring ; there is a greater power of 
determining the value of facts, and a less disposition to be 
governed by the emotions. 

But after a time the intellect becomes less absorptive of 
perceptions and less creative of ideas. The power of mental 
concentration is markedly diminished. The memory fails, 
especially in regard to recent occurrences. The imagination 
loses the vividness and extensive range of youth and maturity, 
and the judgment becomes feeble and vacillating. The indi- 
vidual begins to rely on others for advice as to his affairs, and 
little by little he parts with his own will, even in matters of 
the smallest importance. The emotions no longer sway the 
whole being as they once did, and some of them are utterly 
extinguished. Often, however, a maudlin or fretful condition 
is developed, which ends with its own expression of tears or 
sniffles, never prompting to volitional impulses or producing 
more than a momentary disturbance. 

To all this, however, there are sometimes notable excep- 
tions, but yet not enough to invalidate the law that the period 
in question is one of decline in fact as well as in name. 

If the alterations are gradual and uniform throughout the 
system, death from old age is the consequence ; but it rarely 
happens that derangement of some one important function 
does not produce this result before the general breaking-up 
of the vital principle occurs. 

During the first ten or fifteen years the decay of the organ- 
ism is so slowly effected that very little inconvenience results, 
and occasionally, as has been intimated, we meet with indi- 
viduals who are able to withstand, to a very advanced period 
of existence, the tendency to degeneration. But it is never- 
theless advancing, imperceptibly it may be, but surely, to the 
extinction of the principle of life. 

Such is a brief outline of some of the conditions which at- 
tend the period of decline. The diseases to which it is espe- 
cially liable are those which are connected with the most im- 



100 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

portant organs of the body — apoplexy, paralysis, and mental 
affections being chief among them. 

Owing to the failure of the nutritive processes of the brain, 
the power of this organ is so greatly diminished that what is 
known as senile dementia is a not infrequently engendered 
pathological state during the latter portion of the period of 
decline. This condition, which is the result of pathological 
changes in the brain, rarely makes its appearance before the 
sixtieth year, and generally not till much later. Willie 1 has 
shown that there is a positive shrinking of the brain in size 
and weight, to which, doubtless, the failure of mental power 
is directly due. 

General paralysis, though met with in both the other peri- 
ods, is far more frequent after the age of thirty-five, when the 
system has reached its acme, than at any other part of life, 
or, in fact, than both the others combined. 

The cessation of the menstrual flow in women, occurring 
as it does during this period, is a prolific cause of mental 
alienation. 

But the individual who has attained to an advanced age 
without suffering from any form of insanity is generally safe 
for the rest of his existence. Acute mania is rarely met with 
in these persons, and melancholia, though more common, is 
nevertheless comparatively infrequent. It is not, indeed, to 
be expected that, with the exception of senile dementia, old 
age, when the intellect is dulled and the passions burned out, 
can afford many examples of active mental alienation. I have, 
however, witnessed a few cases of what Morel calls senile in- 
sanity (folie senile) occurring in very old men and women. 
In some of its features it is not unlike general paralysis ; but 
it has altogether a different course and character of termina- 
tion. There are the same mental exaltation and weakness of 
the muscular system, conjoined with a peevishness and disre- 
gard for the rights and feelings of others which tend to render 
the subjects a nuisance to those about them, at the very time 
that they should be exhibiting the calmness and dignity of a 
majestic old age. It generally ends either in an attack of 
acute menengitis or of cerebral haemorrhage, which quickly 
carries off the patient. 

1 u Des psychoses de la senilite," Allgemeine Zeitschrift fur Psychiatrie, 1873. 



SEX. 101 

CHAPTER XII. 

SEX. 

At birth, and for some years afterward, the differences 
which exist between the sexes are scarcely noticeable, except 
so far as different conformation of the generative apparatus is 
concerned. After puberty other evidences of distinct organ- 
ization appear, and the several peculiarities which mark the 
sexes become manifest. In the male the voice becomes rough, 
the penis and testicles enlarge, spermatozoids appear in the 
seminal liquor, the chest becomes broader and deeper, and 
hair makes its appearance on the face, the axillae, and pubes. 

In the female the pelvis enlarges, as do also all the organs 
of generation ; the function of generation, which consists in 
the periodical discharge of an ovum, accompanied by a flow 
of blood from the uterus, begins, and hair grows upon the 
axillae and pubes. In a short time each sex has fully assumed 
all the characteristics, both mental and physical, which belong 
to it, so that an observer is enabled by a casual inspection to 
determine at once the sex of the individual. In early child- 
hood these differences are so slight that, without an examina- 
tion of the genital organs, it is often impossible to make the 
discrimination in question. 

Besides these influences there are others of a more general 
character. The male is stronger and more coarsely and com- 
pactly built ; his features are more marked and prominent ; his 
muscles are more developed ; his bones are larger ; his whole 
frame taller and broader. In addition, his nervous system, 
though capable of greater endurance, is not so sensitive to 
delicate impressions. On the other hand, the female is more 
slightly and finely organized. Her skin is softer, her features 
smaller, her muscular system less powerfully developed, her 
circulation less active, and her figure shorter and more slender. 

The capacity of the skull is greater in the male than in the 
female, and it is remarkable, as Yogt * has shown, that the 
difference in favor of the male increases as the race becomes 
more civilized. Thus, in savage nations, as the negroes of 
Africa, the male and female skulls are much more alike in 
capacity than they are in Europeans. Thus Huschke, 2 of 

1 " Lectures on Man," "Anthropological Society Publication," p. 90. 

2 " Schadel, Hirn und Seele," Jena, 1854. 



102 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

21 male Germans, found the average cranial capacity to be 
1,538*76 cubic centimetres, while of 18 female Germans it was 
only 1,265 '23 cubic centimetres, a difference of 273*53 cubic 
centimetres. Barnard Davis, 1 of 12 male Australian skulls, 
found the average capacity to be 1,316*85 cubic centimetres, 
while of three Australian women it was 1,273*08 cubic centi- 
metres, a difference of only 43*77 cubic centimetres. The 
largest number of measurements is given by Mantegazza. 2 Of 
191 male skulls he found the average capacity to be 1,451 
cubic centimetres, and of 101 female skulls the average capa- 
city was 1,338 cubic centimetres, a difference of 113 cubic cen- 
timetres in favor of the male skull. 

On this point there is no difference among anthropologists, 
and it may be considered as a settled question that the cranial 
capacity of the human male is greater than that of the female. 

It would naturally follow that, where there is a relatively 
larger cranium, there would be a relatively larger brain, and 
this is exactly the case when the male brain is compared with 
that of the female. The difference has been variously given 
by authors, according to the nationality of the subjects, but 
the average, as established by Welcker's 3 observations, appears 
to be about as correct as such determinations can be made. 
He found the average male brain to weigh 1,390 grammes, or 
a little over 49 ounces, and the average female brain 1,250 
grammes, or a little over 44 ounces, a difference of about 5 
ounces. The proportion existing between the two is, there- 
fore, as 100 : 90. This accords with the observations of Thur- 
nam, 4 to which reference was made in the first chapter of this 
work. 

But, relatively to the weight of the body in the two sexes, 
the difference is not so great. The body of the female is 
shorter and weighs less than that of the male. Thurnam de- 
termined the average stature of women to be 8 per cent, less 
than that of men, so that, relatively to her stature, the brain 
of a woman is but 2 per cent, less than the brain of man. 

1 " Crania Britannica," cited in Revue W anthropologies Paris, 1873, t. ii, 
No. 3, p. 482. 

2 " Dei caratteri seperali dei cranio uinano," Archivio per PAntropologia, t. ii, 
1872, p. 11, etseq. 

3 " Untersuchungen iiber Ban und Wachsthum menschlichen Schadels," 
Leipzig, 1862. 

4 " On the Weight of the Human Brain and on the Circumstances affecting 
it," Journal of Mental Science, April, 1866. 



SEX. 103 

Quain, 1 summing up the results arrived at by Clendenning, 
Tiedemann, and Reid, states that, "In a series of 81 males 
the average proportion between the weight of the brain (en- 
cephalon) and that of the body at the age of 20 years and 
upward was found to be 1 to 36*5 ; and, in a series of 82 
females, to be as 1 to 36 -46." According to these figures the 
proportionate weight of the brain to the body does not differ 
materially in the two sexes, but what difference there is is in 
favor of woman. The particular point, however, is not of 
much importance psychologically, however interesting it may 
be as a matter of anatomy. If the intelligence depended on 
the weight of the brain relative to the weight of the body, we 
could increase or diminish the power of the mind by systems 
of dietetics. It has not been observed that very thin men are 
remarkable for their mental vigor, or that very fat ones are on 
the verge of imbecility. 

Some years ago I performed a series of experiments rela- 
tive to the comparative specific gravities of the male and 
female brains, which lead, I think, to important results. It 
is not necessary to go into all the details of them as they 
relate to the several parts of the encephalon. I will state 
them so far only as they refer to the gray and white matter of 
the cerebrum. Twenty brains of each sex were examined, and 
the results are as follows : 

Men. — Gray substance. — Maximum, 1*0372 ; minimum, 
1-0314; mean, 1*0350. White substance.— Maximum, 1*0472; 
minimum, 1*0341 ; mean, 1*0427. 

Women. — Gray substance. — Maximum, 1*0325 ; minimum, 
1*0291 ; mean, 1*0317. White substance. — Maximum, 1*0386 ; 
minimum, 1*0311 ; mean, 1*0379. 

It is thus seen that both the gray substance and the white 
are specifically heavier in the male than in the female brain. 

Relative to the proportionate development of the different 
parts of the brain in males and females, Schwalbe a has col- 
lected the data of most importance. 

Huschke regarded it as an essential point of difference 
between the male and the female brain that, in the latter, the 
distance of the upper end of the fissure of Rolando from the 
apex of the frontal lobe, compared with the distance of the 
same point from the apex of the occipital lobe, is much less 

1 " Anatomy of the Human Body," vol. ii, p. 580. 

2 "Lehrbuch der Neurologie," Erlangen, 1880, p. 574, et seq. 



104: PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

than in man. Thus, if the entire length of the hemisphere be 
= 100, there will be found in woman 31 3 in front of the upper 
end of the fissure of Rolando, while in man there will be 43*9. 
Huschke concludes from this that in man the frontal lobe is 
more developed than it is in woman, and that the same is also 
true of the frontal convolutions. This preponderance of the 
frontal convolutions in man, Schwalbe continues, has likewise 
been pointed out by R. Wagner as a characteristic sex dif- 
ferentiation. At all events, it appears to be established by 
Huschke's investigations that, in the female, the parietal pre- 
dominates over the frontal lobe. Finally, his statement that, 
in woman, the fissure of Rolando and also the central convo- 
lutions are more perpendicular than in man, as a consequence 
of the influence exerted by the conformation of the cranium, 
is generally recognized as correct. Rudinger asserts that a 
typical point of difference between the male and the female 
brain can often be found in the seventh or eighth month of 
foetal life, in that the former has the frontal lobe better devel- 
oped than the latter, and that there is an earlier development 
of secondary fissures in it and the parietal lobe. 

These differences of structure would appear to indicate 
differences in mind, and that such differences do exist no one 
who has studied, even cursorily, the course of mental devel- 
opment in the male and female of the human species can doubt. 
It is not necessary that one should be superior to the other, 
but that they should be different is an essential deduction 
from a consideration of the anatomical features of the organ 
as it exists in man and woman. There are some things in 
which man excels, there are others in which woman is his 
superior. To enter fully into the discussion of the subject 
now is not my purpose. I will only remark that the system 
which seems to be coming into vogue, of giving a girl exactly 
the same kind of education as a boy, is, to my mind, supremely 
absurd. The two sexes may move along paths which approach 
parallelism at some points of their course, but they can never 
travel exactly the same road till they have brains presenting 
exactly the same anatomical configuration and structure. 

The beginning of menstruation and its cessation constitute 
critical periods in the life of the female, and exert a great in- 
fluence upon her health and mortality. 

The first discharge is accompanied, ordinarily, by a variety 
of abnormal circumstances, such as headache, fever, nervous 



SEX. 105 

derangement, pain in the loins and uterus, etc., and even the 
subsequent returns are often thus attended. 

The function of those who are healthy in this respect con- 
tinues about thirty years, when it becomes more or less irregu- 
lar, and finally ceases altogether. In some women it is very 
irregularly performed from the first, and this derangement, 
when it exists, is a fruitful source of the great variety of 
nervous and debilitated conditions from which so many women 
of modern society suffer. Perhaps it is not saying too much 
to express the opinion, which my experience assures me is 
well founded, that there is scarcely a woman belonging to the 
upper classes of society who is not more or less irregular in 
her menstrual discharges, and this, too, from causes which 
are the result entirely of an artificial and abnormal mode of 
existence. Exposure to cold and damp when thinly clothed 
or shod, late hours in exciting society, the reading of modern 
works of fiction, which too frequently excite unduly and un- 
healthily the feelings of a sensitive girl, the avoidance of the 
duties and obligations of maternity, the cramming of the mind 
at school with subjects such as civil engineering, differential 
and integral calculus, and other mathematical studies, which 
it grasps with difficulty, influence materially the nervous sys- 
tem primarily, and secondarily the generative organs. These, 
again, react upon the brain, the spinal cord, and the sympa- 
thetic ganglia, and hysteria, hypochondria, and other forms 
of quasi insanity are produced, to say nothing of neuralgia, 
spinal irritation, epilepsy, chorea, nervous dyspepsia, and a 
dozen other diseases as bad or worse. 

As already intimated under another head, the period of the 
beginning of menstruation sometimes leads to very decided 
conditions of mental derangement. In the preceding chapter 
I have cited a case in point from my own experience, and one 
or two additional instances can scarcely fail to be instructive 
to the student of mental pathology. 

A girl aged sixteen, who had never menstruated, but who 
had suffered no special bodily inconvenience from the circum- 
stance beyond severe periodical headaches, was brought to me 
to be treated for what was regarded by her friends as insanity, 
and which was only manifested by an overpowering impulse 
to set fire to houses. She had made seven distinct attempts, 
all, however, on the dwellings of members of her own family, 
and hence, as none were successful, she had hitherto escaped 



106 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

exposure. When questioning her, and examining her thor- 
oughly in other respects, I could discover no defects in her 
reasoning processes, and no delusions. She was fully aware 
of her tendency, and regretted, so far at least as words and 
manner could go, her inability to control herself. 

The impulse only came over her once a month, in conjunc- 
tion with her headache. Scarcely felt as more than a slight 
impression at first, it grew by degrees, till it finally became so 
powerful that, as she expressed it, she felt as though she 
would go wild if she longer resisted. She compared the men- 
tal condition to the sensation (anxietas tibiarum) sometimes 
experienced in the legs when they have been kept long in one 
position, and which causes persons to feel as though, come 
what may, they must move them. Immediately on setting 
fire to a building the impulse disappeared, and did not return 
for a month. Latterly, she had been so closely watched that 
she had not been able to indulge in her proclivity, which 
passed off in a few hours, though not without a considerable 
degree of excitement, almost maniacal, being produced. 

In another case, the patient, a girl of fifteen, had made an 
attempt to kill her brother, an infant, by strangling it as it 
lay asleep in the cradle. She had been placed in charge of 
the child while her mother went out on some errand. While 
sitting watching it, and, as she asserted vehemently, not at all 
weary of her task, the idea suddenly came into her mind to 
strangle the child. She accordingly took off one of her garters 
for the purpose, and placed it around the neck of the sleeping 
infant, but without drawing it tight. For a little while this 
appeared to satisfy her, and she got a book and sat down to 
read. But again the idea occurred to her, and this time 
stronger than before. She dropped her book, and, going 
down on her knees, prayed to be delivered from the instiga- 
tion of the devil, but still the idea increased. Finally, she 
went to the door to call some one to her assistance, but, before 
she could open it, the impulse became so overwhelming that 
she rushed back to the cradle and buckled the garter as tight 
as she could around the throat of the sleeping child. Then 
she rushed out of the house, crying, "I have killed my 
brother ! I have killed my brother ! " The first person she 
met was her father, coming home to his midday meal. He, 
not fully comprehending, but inferring that something ter- 
rible had happened, hurried back with her, and arrived not 



SEX. 107 

an instant too soon to tear off the band and save the child's 
life. 

Previous to this occurrence the girl had evinced no evi- 
dence of mental derangement. She had regularly attended a 
public school, and had stood well in her classes. She had 
begun to menstruate at fourteen, but the function had been 
only twice performed when it stopped. I could discover no 
sign of insanity, or of even the least abnormality in the action 
of the mind. She begged, however, that she and the child 
might not, in future, be compelled to remain in the same 
house, as she was afraid she would strangle it yet, if she had 
the opportunity. 

I may add that both these cases recovered under treatment. 

Several other cases which have come under my care or 
observation will receive consideration under their proper 
headings, when the subject of insanity comes to be fully dis- 
cussed. 

The chief feature of the mental derangement occurring at 
the beginning of menstruation is the impulsive or instinctive 
character of the manifestations. As I have said ' on a former 
occasion, with reference to women generally, and especially 
with regard to the case of Constance Kant, who was accused 
of, and who confessed to, the murder of her infant brother : 

" Their likes and dislikes are conceived upon the most 
trivial, and often most erroneous, grounds : they are subject 
to very whimsical and really ungovernable fancies ; their 
nervous systems are disordered, and thoughts may be con- 
ceived and acts committed which, at a subsequent period, 
would fill their minds with horror. Numerous instances of 
the kind have come under my observation, and physicians 
generally will, doubtless, recognize the truth of what I say. 
Though, in the great majority of young girls who are brought 
up under proper influences, these psychological evidences of 
the great change the organism is undergoing rarely make 
themselves manifest to any but those with whom they are 
thrown into intimate relations, this is, unfortunately for 
human nature, not always the case. A slight derangement 
in the physiological processes which are going on may pro- 
duce simply an appetite for chalk or slate-pencils ; a transient 
vertigo may cause a radical and permanent change of charac- 

1 " The Medico-Legal Value of Confession as an Evidence of Guilt," " Jour- 
nal of Psychological Medicine," vol. v., 1871, p. 357. 



108 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

ter ; an almost unnoticed congestion of the brain may prompt 
to the commission of a horrid crime. Even an adult man is 
never the same after as before an attack of cerebral congestion 
or haemorrhage. From having been kind, considerate, and 
gentlemanly, he may become changed to a being of morose 
and brutal instincts, which it is impossible for him to restrain 
within bounds. With how much greater force would these 
or similar influences act upon the impressionable nervous 
organism of a girl when at the most susceptible and critical 
stage of her existence ! " 

Delasiauve, 1 among others, has called attention to the ab- 
normal mental condition in which women are sometimes 
thrown at each menstrual period. He has noticed the exag- 
gerated desires, the eccentric appetites, the inexplicable aver- 
sions, and especially the instinctive perversions, which impel 
them to the perpetration of criminal acts. 

Occasionally, women or girls under such circumstances 
falsely accuse themselves of all kinds of horrible crimes and 
disgusting obscenities. Doubtless this is sometimes the re- 
sult of the morbid desire for notoriety, at any cost, with which 
they are afflicted, but there is no doubt that they are not in- 
frequently sincere, actually believing that they are the guilty 
monsters they represent themselves to be. During the mid- 
dle ages it was by no means an uncommon thing for young 
girls just beginning menstruation to allege that they had had 
sexual intercourse with the devil and other demons, that they 
participated in the orgies of the " Sabbath," or that some 
monk or priest had, through the power of Satan, bewitched 
and seduced them. Epidemics of alleged " possession " and 
sorcery, clearly due to menstrual derangements, swept through 
the countries of Europe, and led, by the false accusations and 
confessions of the affected nuns, to the sacrifice of many inno- 
cent persons. 3 

But occasionally the form of insanity developed is of a 
much more active character. Marc 3 cites the case of a girl 

1 "Folie occasionne par la menstruation," Journal de medecine mentale, t. iv, 
1864, p. 241. 

2 For a more complete consideration of this and analogous subjects, the reader 
is referred to the author's work, " On Certain Conditions of Nervous Derange- 
ment," New York, 1881. 

3 " De la folie consideree dans ses rapports avec les questions medico-judi- 
ciaires," Paris, 1840, t. i, p. 317. 



SEX. 109 

who, at each menstrual period, was attacked with furious 
mania, during which, with a knife in her hand, she attacked 
those who displeased her or went in the slightest degree in 
opposition to her wishes. 

In an instance that came under my own care, the patient, 
a young lady, at the beginning of one of her earliest men- 
strual periods, without any preliminary indications, rushed 
from the house and ran down the street screaming at the top 
of her voice, and imploring those she met to save her. As 
it afterward appeared, she had suddenly, while sitting in the 
drawing-room talking with her mother, been seized with the 
delusion that a large negro man was entering the house 
through the window, and that he was pointing a pistol at her. 
At each period for several months she had a similar delusion, 
but eventually she was cured. 

Sometimes the only mental faculties which are disordered 
in their action are the perceptions, causing the production of 
illusions and hallucinations. Thus, one young lady, who was 
under my care, always at her menstrual periods had visions 
of heads and hands floating about in the air near her. They 
were scarcely ever absent during the whole duration of the 
discharge. Another saw friends who had long been dead, 
and who came and sat beside her and talked with her ; and a 
third had constant hallucinations of hearing voices whisper- 
ing to her, and telling her to do all kinds of ridiculous acts. 

At times, but in my experience not often, there is mani- 
fested a very high degree of exaltation of the sexual instincts, 
and even a depravation of them, constituting the form of in- 
sanity known as nymphomania. During the paroxysms of 
this disease the patient exhibits the most shameless de- 
meanor, indulging in the most obscene gestures and language, 
conjoined sometimes with maniacal excitement, much agita- 
tion, tearing off the clothing, and violence toward herself or 
others— and all this although her education and associations 
may have been of the most refined character. 

But the period of the beginning of menstruation, if a fruit- 
ful source of mental and nervous disorders, is almost equally 
often a curative agent of like affections. Epilepsy is fre- 
quently spontaneously arrested at the inception of the men- 
strual function, and so also are the several forms of insanity 
which may have begun in earlier life. Thus, a very distress- 
ing but interesting case of acute mania, occurring in a young 



110 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

lady twelve years of age, was suddenly cured on the appear- 
ance of the catamenia, at the age of fourteen. In another 
case, which also came under my observation, the patient, a 
girl of about eleven years old, was affected with religious mel- 
ancholy, which disappeared between the second and third 
menstrual periods, at the age of thirteen ; and in a third in- 
stance—the one to which reference has been made in the last 
chapter — menstruation had been delayed, but, on its being 
brought on by treatment directed to that end, the mental dis- 
order, quickly yielded. Many like instances are on record, 
but the following are so striking that I cite them for the 
instruction they are capable of affording : 

Buisson ' reports the cases of two girls, aged, respectively, 
twelve and thirteen years, who imagined themselves bewitched 
by eating potatoes given to them by an old woman to whom 
they had refused alms. They were taken with vomiting, 
convulsions, and maniacal fury, during which they lost the 
faculty of speech, and committed a thousand extravagant 
acts. After a strong purgative, exhibited probably for the 
purpose of relieving the bowels of any undigested substances, 
the delirium increased, but, the menses also appearing, they 
soon became calm, and remained entirely cured. 

And this from Grirard : 3 

A thread- winder, aged twelve, of a nervo-sanguineous tem- 
perament, suffered from pain in the. stomach and bowels, 
cramps, difficulty of breathing, and the globus hystericus. 
The morbid condition lasted for two years, at which time the 
following symptoms were noticed : constipation, pain on 
pressure over the abdomen, irregular distribution of heat, 
frequency of pulse, and general hypersesthesia. She then 
entered the Hotel Dieu, at Lyons. On the second day she 
was delirious, had hallucinations of sight and smell, and pains 
in the thighs and lumbar region. The following day there 
was a slight menstrual flow. Immediately all the symptoms 
began to disappear, and, in less than three weeks from her 
entrance into the hospital, she was discharged cured. 

The period of the cessation of the menstrual discharge is 
also one which exercises great influence over the health of the 
individual, and especially so far as the mind is concerned. It 
is often the determining agent when hereditary or other pre- 

1 Quoted by Berthier in " Des nevroses menstruelles," Paris, 1874, p. 220. 

2 Quoted by Berthier, op. cit., p. 225. 



SEX. HI 

disposition exists to mental disease, and, even when there is 
no such tendency, acts as its own immediate canse. 

Most authors upon the subject of insanity have noticed the 
relation between the menopause and the initiation of symp- 
toms of mental derangement. Generally the melancholic type 
prevails, and a tendency to suicide is not uncommon ; but 
quite often there are various forms of emotional disturbance 
or of perversion of the appetite, which are sources of great 
distress to friends and relatives. 

Semelaigne * has noticed a fact in this connection to which 
my attention has also been drawn, and that is, the develop- 
ment of the desire for spirituous liquors as a beverage, produc- 
ing, in some cases, a veritable form of insanity. As he says, 
the nervous perversions caused by menstruation are princi- 
pally occasioned by the cessation of that function, which pro- 
vokes, with many women, an irresistible temporary or per- 
manent propensity to drink alcoholic liquors to excess. In 
the beginning, the unhappy subjects take their potations in 
secret, but, little by little, they lose all sense of shame, and 
do not hesitate to exhibit in public the spectacle of their de- 
plorable infirmity. Neither rank nor education is any obsta- 
cle to the indulgence of this appetite. To procure their fa- 
vorite liquor there is no deceit they will not practice, or 
watchfulness they will not evade. If the accustomed stimu- 
lus cannot be had, they will resort to the use of anything 
else that contains alcohol. I have known women, under these 
circumstances, to drink cologne- water, bay -rum, all kinds of 
medicinal tinctures, and, in one case, the alcohol that was 
used to preserve morbid anatomical specimens. 

In recent years the appetite for opium, in some one or 
more of its forms, and chloral, has become developed to a 
great extent, and I have seen enough of it to know that it, 
too, is more prone to be exhibited in women at about the 
period of the cessation of the menstrual flow than at any other 
time. While not so deleterious, either to body or mind, as the 
morbid appetite for alcohol, either of these substances, or,- 
indeed, any narcotic, sedative, or stimulant, if used to excess, 
and as a means of procuring pleasant thoughts, or banishing 
unpleasant ones, is certain, eventually, to lead to great mental 
and bodily disorder. 

1 " Du diagnostic de la dipsomanie," Journal de medicine mentale, t. i, 1861, 
p. 212. 



112 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

Abnormal, erotic, or nymphomaniacal tendencies are some- 
times excited by the cessation of the menstrual flow, and con- 
stitute some of the most distressing cases the physician is 
called upon to treat. In a case of the kind which I saw sev- 
eral years since, the patient, a married woman, aged forty-six, 
in whom there was no discoverable hereditary influence toward 
insanity, at the time that her catamenia were beginning to 
become irregular was seized with libidinous desires, altogether 
abnormal in character. Previously she had never exhibited 
any marked sexual proclivity, and intercourse rarely gave her 
any pleasure, but now she was continually making indecent 
propositions to men whom she met, even in the most public 
places, and in the presence of her own husband. She remained 
in about the same condition for two years, and then, the 
menses ceasing altogether, she recovered her health. 

Another, a single lady, was, at the period of the meno- 
pause, affected with hallucinations of sight, of the most ob- 
scene character, and which haunted her night and day. 

Todd cites the case of a Madame X., the mother of ten chil- 
dren, all of whom she had herself suckled, who began at forty- 
five to suspect the faithfulness of her husband. Later, she 
accused him of attempting to murder herself and her chil- 
dren. A slight improvement in her condition was obtained 
by sequestration, but eventually the symptoms returned with 
nymphomaniacal manifestations. 

In insane women it is not an uncommon circumstance for 
sexual aberrations to occur on the supervention of the meno- 
pause. 

In man the accession of puberty is not so efficient an agent 
in the production of mental disturbance as it is in woman, 
though occasionally it appears to be the cause of either well- 
marked lunacy, or of such a perversion of the moral nature as 
constitutes a condition of quasi insanity. There being no 
physical sign appearing suddenly, like menstruation, it is 
difficult to associate puberty and mental derangement in boys 
as cause and effect. Still we do see cases in which, apparently, 
such a relation exists. We have some right to form such an 
inference if no other cause can be properly alleged. In the 
case of a young man, aged fifteen, recently under my charge, 
I could find no other probable factor than puberty, for the 
maniacal perversion of the mental faculties which existed. 
There were hallucinations of sight and hearing, and the fixed 



SEX. 113 

delusion that he was a person whom he designated Sir Peter 
Trimble, and who, he claimed, was the greatest traveller the 
world had ever known. He wonld sit by the hour, imagine 
himself to be in Central Africa, at the north pole, in China, 
Brazil, and other places, real and hypothetical, and carry on 
conversations with the natives whom he saw and heard. This 
he kept np day after day with wonderful versatility, rarely 
visiting the same place twice, or, if he did, evidently encoun- 
tering different adventures from those which had befallen him 
on his first visit. There was one exception to this, however. 
Every day he paid a visit to an immense city, as he described 
it, which he called Sarominden, and which he said was in the 
middle of the wilderness in which the Jews, under Moses and 
Joshua, passed forty years. There were no sexual aberrations 
of any kind, as I fully satisfied myself, but there were swollen 
and painful testicles at times. Evidently, sexual intercourse 
would have cured this boy, but I could not find it in my heart 
to say so to his father, though, possibly, in time I would have 
been less scrupulous, had not Nature stepped in to his relief, 
and, by repeated nocturnal emissions, restored the proper de- 
gree of equilibrium between his testicles and his brain. 

But the insanity of this period in boys is more apt, accord- 
ing to my experience, to present the form of u reasoning 
mania." The subject becomes vicious and troublesome, but 
is always ready with specious excuses for his conduct. He 
commits various petty crimes, and is, perhaps, turned out of 
school or his workshop for theft or malicious lying. He runs 
away from home to go to sea, or to become a train-robber, or 
to fight Indians. Again, he has the ' ' delirium of persecu- 
tion." People watch him, he declares, as he walks the streets, 
and whisper about him, evidently forming combinations to 
ruin or murder him. The neighbors, especially those opposite 
his residence, are the objects of his continual suspicion. If a 
blind is closed, it is in order to watch him through the slats ; 
if any one leaves the house, it is to tell a confederate of his 
movements, and so on, without the slightest regard to proba- 
bility, or even of possibility. 

In another case under my charge, the patient, a young man 
of about sixteen years of age, conceived the idea that every 
woman who saw him at once fell violently in love with him. 
As a consequence, he made himself extremely obnoxious to 
many persons, and was continually getting into trouble with 

8 



114 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

the male friends and relatives of His supposed inamoratas. 
Not even several severe beatings which he received were suffi- 
cient to cure him of his delusions, and eventually it was found 
necessary to place him in a private lunatic asylum. He 
escaped from this place without difficulty, and was next heard 
of in Cincinnati, where he figured before a police-court for 
addressing ladies in the street. He was brought home, and, * 
after a year or two, during which he was taken to Europe, 
entirely recovered, and is now in good health. 

Under the head of "Hebephrenia" the insanity of pubes- 
cence will be more fully considered. 

Gall contended that there was a periodical manifestation 
in men analogous to that existing in females, though, of 
course, different from it, and Levy l holds a similar opinion. 
The latter states that " young and robust persons do not 
notice this tendency unless their attention is specially directed 
to it, but men feebly constituted, or endowed with a great de- 
gree of irritability, or who have reached the period of their 
decline, perceive the alteration which their health monthly 
undergoes : their countenance becomes dull, their perspiration 
assumes a strange odor, their digestion is more laborious, and 
sometimes the urine deposits a heavy sediment. The feeling 
of discomfort is general and inexpressible, and the mind par- 
ticipates in it, for it is more difficult to maintain a train of 
ideas ; a tendency to melancholy, or perhaps an unusual de- 
gree of irascibility, is joined to the indolence of the intellec- 
tual faculties. These . modifications persist some days, and 
disappear of themselves. 

I have certainly noticed in some of my friends this ten- 
dency to some monthly periodical abnormal manifestation. 
This may be in the form of a headache, or a nasal haemor- 
rhage, or a diarrhoea, or an abundant discharge of uric acid, 
or some other unusual occurrence. I think this is much more 
common than is ordinarily supposed, and that careful exami- 
nation or inquiry will generally, if not invariably, establish 
the existence of a periodicity of the character referred to. 

The profound changes induced in the female organism by 
the condition of pregnancy could scarcely leave the mind un- 
touched, and we find, in fact, that mental disturbance going 
far beyond the eccentric "longings" of women in this state is 
not an infrequent occurrence. This may exhibit itself mainly 

1 " TraitS d'hygiene," t. i, p. 122. 



SEX. 115 

as regards the emotions, the subjects becoming irascible, sus- 
picious, jealous, or the victims of profound melancholy ; or 
the intellect may be involved, and delusions become charac- 
teristic features of the disorder. Again, they may manifest 
the most unreasonable hatred of certain persons, and may 
make serious attempts to injure or destroy them. 

As Morel - declares, it is a matter of importance to ascertain 
whether the mental alienation exhibited during pregnancy is 
the result of the woman's condition, or whether pregnancy has 
occurred in a subject already insane. This is an important 
point in the formation of a prognosis, for, in the former case, 
the disease will probably disappear with the birth of the child, 
while in the latter no such favorable termination is to be ex- 
pected. "In thirty-eight women," he states, "that I have 
had occasion to treat, and in whom pregnancy was complicated 
with mental alienation, twelve, at least, were degenerated be- 
ings — imbeciles, idiots, or epileptics — in whom pregnancy was 
only an accident that could not have any influence over the 
course of an irremediable state. The majority of these unfor- 
tunate women were delivered, some without manifesting the 
slightest interest, and others without possessing the least 
knowledge of their situation. 

" With seventeen other women the insanity which declared 
itself during the course of the pregnancy was not an isolated 
phenomenon. It was sometimes due to hereditary transmis- 
sion, sometimes to neuropathic conditions pre-existent to the 
pregnancy, and which constituted mental states of a disquiet- 
ing character. It was observed that, in those with a predis- 
position to melancholy, there was, in every case, a great irri- 
tability of disposition, combined with all the attributes of the 
nervous temperament, and a tendency to the perpetration of 
eccentric or unusual acts ; in other cases the hysterical element 
predominated. In three instances the pregnancy had been 
advised as a cure for a hysterical neurosis, but without the 
favorable result that had been expected. It is also to be 
noted that the greater number of these women were not 
primiparse. Some had been pregnant two or three times, and, 
after each labor, a greater disposition to contract a mental dis- 
ease had been observed." 

Insanity in pregnant women is most apt to make its ap- 
pearance during the fourth month of gestation. 

1 " TraitS des maladies mentales," Paris, 1860, p. 202. 



116 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

As stated by Morel, in the passage quoted, pregnancy is 
sometimes recommended as a cnre for a pre-existing mental 
derangement. Esquirol l states that, though pregnancy, child- 
birth, and lactation, are means which Nature sometimes adopts 
for curing insanity, yet such a favorable termination is rare. 
Though he has often seen childbirth render a maniac more 
calm, and though, in the case of a lady who, at each of five 
pregnancies, became insane, to be cured at each delivery, he 
nevertheless regards such cases as quite exceptional ; and that 
he has often seen insanity not only persist but become aggra- 
vated by these conditions. 

Dagonet 2 confirms this opinion, and cites the case of a 
young girl, the subject of nymphomania, whose condition 
was rendered much worse by pregnancy and childbirth. 

I have never known marriage entered upon for the purpose 
of curing insanity, but I have repeatedly had it suggested to 
me for my opinion, and I have always advised against such a 
course. 

During or soon after childbirth, in the period intervening 
before the re-establishment of the menstrual discharge, the 
mother is liable to a peculiar form of insanity, known as puer- 
peral mania. This, as a distinct type of mental alienation, 
will engage our attention further on. 

The period of lactation is also of considerable influence in 
causing insanity, especially with those who do not suckle their 
children. The form of insanity is generally similar to that 
which follows childbirth, and by many authors is regarded as 
essentially the same condition. 

Marce states that the sex of the child borne by the mother, 
or nursed by her, is sometimes a determining cause of insan- 
ity, women, he says, becoming the subjects of mental aliena- 
tion after having given birth to male infants, while with every 
female child they have remained exempt. As he further says, 
these facts, at first sight, seem inexplicable, till we recall to 
mind the circumstances that the male child is larger, and, 
consequently, is born with more difficulty than the female, 
and that it sucks the breast with more vigor, and hence 
makes greater demands upon the mother for sustenance. 
I have not noticed any difference in this respect, nor do I 

1 " Des maladies mentales, 1 ' Paris, 1838, t. i, p. 193. 

a " Nouveau traite elementaire et pratique des maladies mentales," Paris, 1876, 
p. 498. 



RACE. 117 

think it has been observed to exist among the women of this 
country. 

Notwithstanding all these factors, which are only effective 
with the female sex, there are others acting with so much 
greater force on males as to canse insanity to be much more 
common in them than in females. The cares incident to pro- 
viding for a family, the anxieties and wear and tear of mind 
connected with business and other affairs of the world, and, 
above all, excessive indulgence in the use of alcoholic liquors 
and of the sexual organs, and many other influences that will 
be more specifically considered under another head, are so 
many powerful agents acting with far greater force on men 
than on women, and hence aiding in making them more liable 
to insanity. 

Another series of causes tending to make mental alienation 
more common in men than in women are those which arise 
from exposure to inclement weather, the direct rays of the 
sun, noxious vapors and emanations, and to various accidents 
and injuries, producing wounds of the head. 



CHAPTER XIII. 

RACE. 

The several races of men are distinguished by great differ- 
ences — so great, indeed, that they can scarcely be regarded as 
due to any other cause than a diversity of origin. Climate, 
hunger, destitution, disease, exposure, degradation, vicious 
habits and appetites, will, in the course of time, produce many 
alterations in the form and aspect of organic beings, but they 
cannot so alter original types as to cause a race, whether of 
plants or of animals, to lose its identity. Thus, the several 
varieties of the cabbage are all derived from a wild plant, 
scarcely edible, growing on the sea-coast rocks of Great Brit- 
ain. The many kinds of apples all come from a common stock 
— the crab-apple. The peach, the most luscious of our fruits, 
has its origin in the bitter-almond of Persia. Yet, however 
much these plants, and many others that might be men- 
tioned, may have varied from the parent growth, they all 
evince a tendency to return to the original form when sepa- 



118 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

rated from the influences which have given rise to the de- 
viation. 

So with the various alterations which animals have under- 
gone through the action of a changed mode of life, or a differ- 
ent climate, continuing through many generations. Restore 
them to their former conditions of existence, and in a short 
time the original type is reached. Take, for example, the 
sheep. The fleece of this animal consists of two kinds of wool 
intermingled ; one is formed of coarse, stiff hairs, the other of 
short, fine, curly wool. In the merino- sheep this latter is 
greatly in excess, and hence the value set on fabrics made of 
it ; but, if the animal is removed to a colder region than is 
natural to it, the coarse, straight hair takes the place of the 
softer variety, and the value of the whole growth is lost. Re- 
place the merino-sheep in its native climate, and the soft wool 
soon again becomes predominant. 

The turkey, which is found wild in this country, is of a 
brownish-black color ; by the mere act of domestication it be- 
comes wholly changed in its markings, and is frequently met 
with entirely white. If, however, it is allowed to run wild 
again in its native forests, the original uniformity of hue is 
soon resumed. 

Other animals, under like circumstances, become changed 
in the form of their ears, the shape of their skulls, or the 
character of their horns ; but these variations, like the others 
mentioned, have nothing of permanence about them. They 
merely exist while the conditions which gave rise to them are 
in force. 

Now, with the several races of mankind the case is alto- 
gether different. There are, it is true, certain changes wrought 
in the physical appearance of man through unfavorable cli- 
mate and the degenerating influences mentioned. And there 
are other alterations produced by the action of agents capable 
of developing his mental and physical organization ; but these 
are quite as transitory in their character as those which ensue 
in the lower forms of organic beings, to some of which I have 
just referred, and cannot be held to account for the marked 
peculiarities which distinguish what are known as the races 
of men any more than they will explain the differences which 
exist between the lion and the tiger, the horse and the ass, or 
the Polar bear and his grizzly representative in the Rocky 
Mountains. 



RACE. 119 

Place the Caucasian in the tropics of South America, Asia, 
or Africa, and though his skin may become darker and his 
hair blacker and coarser, he is, nevertheless, though he re- 
mains there for thousands of years, in no danger of being 
taken for an individual of any other race. 

The negro, for nearly four hundred years, has inhabited 
America. During all that period, his mode of life and the cli- 
mate to which he has been exposed are altogether different 
from those natural to him. He has been subjected to human- 
izing and civilizing influences, his animal wants have been sup- 
plied, and yet, except in cases of a mixing of the blood, he 
presents the same aspects as his progenitors, whose represen- 
tatives are figured on the monuments of ancient Egypt erected 
three thousand years ago. Certainly within the historic pe- 
riod there has been no change in the characteristics of the 
white, yellow, brown, and black races of mankind. 

Even in peculiarities which scarcely rise to the height of 
being racial we observe a permanence which seems to endure 
under all conditions. For example, the Jews, for nearly two 
thousand years, have been subjected to varieties of climate, 
and manners and customs as different from each other as can 
be found anywhere on the face of the globe, and yet a mem- 
ber of the nation can be as well recognized under the black 
skin and hair of the African Jew as under the fair skin and 
red hair of his co-religionist of Norway and Sweden. Before 
the war, I never met but one Jew in the ranks of the regular 
army. He had a fair, freckly skin, and hair the color of a 
carrot. He came from Scotland, and he called himself Fer- 
guson ; but he was circumcised, and was as veritable an Is- 
raelite in figure, and in the shape of his eyes, nose, and 
mouth, as any who ever walked the streets of Jerusalem. 

There are great differences to be observed in the cranial 
capacities and cerebral development of the several races of 
mankind. The late Dr. Morton, of Philadelphia, was among 
the first to study this subject. His method of determining 
the capacity of the skull was to fill it with small shot, and 
then, by measuring these in a graduated vessel, ascertain the 
cubical contents. He found that the mean cranial capacity in 
Americans of European descent was 92 cubic inches, in the 
American Indians 79 cubic inches, and in the negroes 83 cubic 
inches. 

The form of the skull is also a matter of racial difference. 



120 PHYSIOLOGY AND PATHOLOGY OF THE MIND. 

Ill the negro, for instance, it is long and narrow, constituting 
the form called dolichocephalic ; in the Tartar it is broad and 
short — bracliyJcephalic ; and in the white or European mesoke- 
phalic — that is, a mean between the two others. 

As regards the weight of the brain in the several races, 
Thurnam ' has collected some interesting statistics, by which 
it appears that the average for male Europeans is about 49 
ounces, and for negroes 44*3 ounces, or 1,390 and 1,255 
grammes, respectively, while, according to Dr. Clapham, 8 the 
average brain weight of eleven Chinese males was 50*45 
ounces, or about 1,430 grammes. These results are so differ- 
ent from what might have been expected that we may reason- 
ably suppose a source of error to have existed. The subjects 
were coolies, and they died during the typhoon in Hong- 
Kong in September, 1874. 

As regards the liability to mental derangement, there are 
very few data at our command, and those we have are compli- 
cated by other circumstances than race, which tend to render 
them of little value. Thus, when it is asserted, and apparently 
with truth, that negroes are less prone to insanity than the 
whites, we do not know how much of this immunity is the 
result of the racial factor, and how much is due to the differ- 
ences in the mode of life, the degree of activity of the mind, 
etc., which exist ; and the like is true of the American Indian. 
Place either one of them, in his youth, in New York, let him 
adopt the manners and customs of the average resident of 
that city, overwork his mind at school, use alcohol to excess, 
plunge into the pursuits of money-making with his whole 
heart and mind, deprive him of a large part of his natural 
rest — sleep — and prevent him from exercising his body to the 
extent it requires, and the probability is that he will be as 
likely to become insane as any white man similarly situated. 
It is certainly true that barbarous nations do not exhibit so 
strong a tendency to mental alienation as do those that are 
civilized, but this is simply because they are barbarous, and 
not because they belong to different races. As nations ad- 
vance in civilization, the tendency to all kinds of diseases of 
the mind is increased, because it is just the very causes 
which make civilization, and the vices which necessarily ac- 

1 Op. cit., loc. cit. 

2 " Journal of the Anthropological Institute of Great Britain and Ireland," 
vol. vii, p. 90. 



RACE. 121 

company it, that are the most potential agents in producing 
insanity. 

It is a matter of certain knowledge that, since the abolition 
of slavery, and the consequent elevation of the American 
negroes in the social scale, the number of cases of insanity 
among them has greatly increased. In his former condition the 
negro had no responsibilities and but little care ; there was no 
opportunity for the exhibition of much emotion, and he there- 
fore showed very little. In their original condition in Africa 
they evinced still less, and probably there, were even less dis- 
posed to mental derangement than in America as slaves. 
Travellers report that the Congo women have so little maternal 
instinct that their living babies may be pounded in a mortar 
to appease some evil spirit, while they look on with indiffer- 
ence. In the old days of slavery the parting of families, sold 
to different masters, rarely caused any marked emotional dis- 
turbance. 

But long association with whites, and, above all, the aboli- 
tion of slavery, by which act they were raised to a position of 
political equality with their former masters, has changed all 
this. The negro now has responsibilities ; he has a wife and 
children whom he can call his own, and whom he is bound to 
support. He votes, goes to school, attends church as a critic 
— selecting his own religion — keeps a shop, or studies some 
profession. All this is beginning to tell upon his mind. 
With its development — and he appears to have capacity for 
considerable mental improvement — the liability to insanity 
has increased, until now special lunatic asylums are being 
established for his accommodation, and they are being filled 
as rapidly as they can be opened. 



SECTION II. 
INSTINCT; ITS NATURE AND SEAT. 



CHAPTEK I. 

TEE NATURE OF INSTINCT. 

A work on insanity would manifestly be incomplete with- 
out some reference to a principle of life present in all organic 
beings, from the highest to the lowest, from the most insig- 
nificant plant to man himself, and which, in all, determines, to 
a greater or less extent, the character of the acts by which 
existence is rendered possible. When we bear in mind the 
fact that, in man, a very considerable proportion of cases of 
mental derangement have their origin in aberrations of some 
one or other of the instincts, the propriety of its consideration 
becomes still more apparent. 

A great deal of confusion has existed among physiologists 
and psychologists relative to the differences between instinct 
and reason, and undoubtedly there are many difficulties in the 
way of distinguishing, with perfect accuracy, the manifesta- 
tions belonging to each. No inconsiderable amount of the 
obscurity has arisen from the loose manner in which words 
have been employed and meanings ascribed to them. I shall 
endeavor, therefore, to give a clear idea of what instinct is, 
and to separate it, by well-defined limits, from mind, before 
proceeding to the consideration of its aberrations. In doing 
this I shall be obliged to quote the views of several eminent 
authorities, in order to show how various are the opinions 
held relative to this primal organic force, often more powerful 
than mind itself. 

Montaigne ' appears to see no difference between the purely 

1 " The Essays of Michael Seigneur de Montaigne," Cotton's translation, p. 
283. (Apology for Raimonde de Sebonde.) 



THE NATTTKE OF INSTINCT. 123 

instinctive operations of the lower animals and those intel- 
lectual acts performed by man. 

" As to the rest," he says, " what is there in ns that we 
do not see in the operations of animals ? Is there a polity 
better ordered, the offices better distributed and more invio- 
lably observed and maintained, than that of bees ? Can we 
imagine that such, and so regular, a distribution of employ- 
ment can be carried on without consideration and prudence ? 

" The swallows that we see at the return of spring, search- 
ing all the corners of our houses for the most commodious 
places wherein to build their nests, do they seek without 
judgment, and, among a thousand, choose out the most proper 
for their purpose without discrimination? In that elegant 
and admirable contexture of their building, can birds rather 
make choice of a square figure than a round, of an obtuse than 
of a right angle, without knowing their properties and effects ? 
Do they bring water and then clay without knowing that the 
hardness of the latter grows softer by being wet ? Do they 
mat their palace with moss or down without foreseeing that 
their tender young will lie more safe and easy ? Do they 
secure themselves from the wet and rainy winds, and place 
their lodgings toward the east, without knowing the different 
qualities of those winds, and considering that one is more 
comfortable than the other ? Why does the spider make her 
web straighter in one place and slacker in another? Why 
now make one sort of knot and then another if she has not 
deliberation, thought, and conclusion? We sufficiently dis- 
cern, in most of their works, how much animals excel us, and 
how unable our art is to imitate them. We, nevertheless, in 
our more gross performances, employ all our faculties, and 
apply the utmost power of our souls. Why do we not con- 
clude the same of them? Why should we attribute to, I 
know not what, natural and servile inclination, the works that 
excel all we can do by nature and art ? " 

There is not one of Montaigne's very apposite questions 
that should not be answered in a way directly the opposite of 
that to which he evidently inclines. All the acts he cites so 
eloquently are very different from those reasonable operations 
which the lower animals do perform, and which theological 
philosophers regard as instinctive. His error is in a direction 
the reverse of theirs. He would make all the acts of animals 
intellectual, while they would give this influence to none. 



124 INSTINCT; ITS NATURE AND SEAT. 

Pascal ' had a more correct idea of the difference between 
instinctive and intellectual acts. " The effects of reasoning," 
he says, "are continually increasing, while instinct remains 
always the same. The cells in the honeycomb of the bee were 
as accurately made a thousand years ago as they are to-day, 
and each insect formed its hexagon as exactly the first time it 
made one as the last. Nature, having no other object than to 
maintain animals in a certain state of perfection, has inspired 
them with the necessary and never- variable science, so that 
they shall not perish, and it does not permit them to add to it 
lest they should pass the limits which have been prescribed." 

While sufficiently indicating the general nature of instinc- 
tive acts, Pascal has committed the error of regarding instinct 
as unalterable. 

Descartes 8 looked upon all the lower animals as being 
more or less perfect automata. Beasts, he says, do many 
things better than we can do them, and, as they invariably 
fail in doing others, it shows that they do not act from knowl- 
edge, but only by the disposition of their organs. He lays 
very great stress on the assumed fact that none of the lower 
animals talk — an assertion which has never yet been demon- 
strated — and from this draws the conclusion that they are 
devoid of reason. But, with more extensive knowledge of the 
structure and faculties of the brain, we know that the ability 
to recollect words, or to articulate them, may be altogether 
abolished in man without essentially impairing his reasoning 
power in other directions. Admitting, therefore, that beasts 
have no faculty of articulate speech, the fact may depend 
upon a lack of development in the speech tract in the brain, 
and is no argument against their possession of reason. 

Further, he declares that there are in man two principles 
which govern our actions : the one entirely mechanical and 
corporeal, which depends solely on the force of the animal 
spirits and the configuration of the parts, and that may be 
called the corporeal soul ; and the other incorporeal, which 
feels and reasons. In animals, all movements can be explained 
by referring them to this one principle, the first-named or 
corporeal soul. The other, the thinking soul, he denies to 
them altogether ; and instinct is nothing more than the orderly 
working of the organs, such as takes place in any machine. 

1 " De l'autorite en matiere de philosophie," t. ii, p. 270, edition Havet. 
3 " Diseours de la methode," V e partie, (Euvres comp. de Cousin, t. i, p. 186. 



THE NATURE OF INSTINCT. 125 

He overlooks the fact, however, that, without a force to start 
the machine and to keep it in action, its parts, though they 
be absolutely perfect in construction, will remain motion- 
less. 

Dr. Reid 1 defines instinct as " a natural, blind impulse to 
certain actions, without having any end in view, without de- 
liberation, and very often without any conception of what 
we do." 

As an example of instinctive motions, he says: "Thus, a 
man breathes while he is alive by the alternate contraction 
and relaxation of certain muscles, by which the chest, and, of 
consequence, the lungs, are contracted and dilated. There is 
no reason to think that an infant new-born knows that breath- 
ing is necessary to life in its new state, that he knows how it 
must be performed, or even that he has any thought or con- 
ception of that operation ; yet he breathes as soon as he is 
born, with perfect regularity, as if he had been taught, and 
got the habit by long practice." 

Dr. Reid's definition of instinct is essentially correct ; but 
the example he gives is altogether irrelevant, showing, there- 
fore, that he had no clear conception of what he was defining. 
He has regarded as instinctive an action which is altogether 
reflex in character. The new-born child does not breathe be- 
cause of " a natural, blind impulse" to do so, but because the 
placental connection with its mother, by which its blood was 
oxygenated, having been severed, and the stimulus of atmos- 
pheric air having been applied to its skin, an impression is 
conveyed to the nerve-centres, is reflected to the respiratory 
muscles, and breathing takes place Both the above causes 
are necessary for the excitation of the respiratory act, for the 
child does not breathe till pulsation has ceased in the cord, 
even though it be entirely expelled from the uterus, nor will 
efforts at respiration be made if access of air be prevented. 

We frequently see the reflex character of the respiratory 
movements demonstrated upon persons who have fainted, or 
who are in stupor or convulsions, and in whom the actions in 
question have been temporarily suspended. A little water 
thrown on the face, a current of air brought to bear upon it, 
or even a feather brushed across the cheeks, will often procure 
a deep inspiration of air. 

1 " Essays on the Power of the Human Mind," Edinburgh, 1803, vol. iii, p. 
126. 



126 INSTINCT; ITS NATURE AND SEAT. 

Of other examples adduced by the same author, many are 
fully as inapplicable as the preceding. 

The elder Darwin ' makes no very clear distinction be- 
tween instinctive and rational actions, except, perhaps, that 
they differ in degree. He cites many examples of what 
are ordinarily considered as belonging to the first-named 
class, but appears to regard them as being the result of in , 
tellection. In the conclusion of his remarks upon the sub- 
ject he says : 

' ' There is a criterion by which we may distinguish our 
voluntary acts or thoughts from those that are excited by our 
sensations. The former are always employed about the means 
to acquire pleasurable objects, or to avoid painful ones, while 
the latter are employed about the possession of those that are 
already in our power." 

According to the same author, many acts which are ordi- 
narily regarded as instinctive are the results of experience 
acquired during foetal existence. Thus, he observes that the 
foetus learns to perform certain movements which are excited 
by a feeling of irksomeness at being kept too long in one posi- 
tion, and that sucking and swallowing are also acquired in 
utero. If, however, all such actions are to be regarded as 
instinctive, the fact that they have been performed does not 
afford any explanation of their origin. It merely places the 
beginning a few months further back, without at all account- 
ing for the cause of their initiation. Indeed, the theory rather 
obscurely enunciated by Darwin, that instinctive actions are 
the consequence of sensitive impressions, does not distinguish 
them from those other actions which are clearly the results of 
reason and will, through the perceptions. Darwin quotes the 
following account of an experiment of Galen's : 

"On dissecting a goat great with young, I found a brisk 
embryo, and, having detached it from the matrix, and snatch- 
ing it away before it saw its dam, I brought it into a certain 
room where there were many vessels, some filled with wine, 
others with oil, some with honey, others with milk, or some 
other liquid, and in others were grains and fruits. We first 
observed the young animal get upon its feet and walk ; then 
it shook itself, and afterward scratched its side with one of its 
feet ; then we saw it smelling to every one of these things that 

1 " Zoonomia, or, The Laws of Organic Life," American edition, vol. i, Phila- 
delphia, 1812, art. "Instinct," p. 101, et seq. 



THE NATUEE OF INSTINCT. 127 

were set in the room, and, when it had smelt to them all, it 
drank np the milk." 

This passage has been cited by many anthors, as affording 
a beantiful example of instinct, whereas, I think, a little re- 
flection will satisfy the majority of thinking persons that the 
action described was purely rational and volitional, and one 
which evinced a great deal of discrimination on the part of 
the prematurely born kid. It took that food which gave the 
most pleasurable sensation to its sense of smell. It deliber- 
ately made a choice — the result of comparison and judgment. 
There was nothing instinctive, nothing blind or impulsive. 
If the kid had not smelt the other substances, but had drunk 
the first one it touched, the action might have been due to a 
force which it could not resist, and which might then have 
been regarded as instinctive. 

Broussais s falls into the error of regarding all instinctive 
acts as being due to impressions made upon the senses, and 
likewise fails to distinguish between such actions and those of 
a reflex character. The want of health, hunger, thirst, etc., 
are, therefore, in his opinion, the excitants of motives — respi- 
ration, eating, drinking — which are instinctive. But, in fact, 
such functions are no more kept in operation by instinct than 
are any other acts which an individual is in the habit of doing, 
or which he deems it necessary or proper to perform. As well 
might it be said that, if a person imperatively requires a cer- 
tain book from a shelf in his library, he is actuated by instinct 
if he rises from his chair and gets it. 

Hartley 2 is more correct than the authors cited when he 
says that instinctive actions are not the results of external 
impressions. This germ of lucidity is, however, so mixed up 
with mystical and confused ideas relative to his theory of 
vibrations that it is difficult to arrive at a clear conception of 
his entire meaning. 

Sir T. C. Morgan, 3 on the contrary, regards instincts as be- 
ing due to sensational impressions. He says : 

" Those impressions which excite a certain degree of pleas- 
ure or pain, or which experience has associated with those 
affections, stimulate the cerebral system to volition, an action 

1 " A Treatise on Physiology applied to Pathology " (American translation), 
Philadelphia, 1826, p. 77, etseq. 

2 " Observations on Man," etc., London, 1792, p. 243. 

3 " Sketches of the Philosophy of Life," London, 1818, p. 292. 



128 INSTINCT; ITS NATURE AND SEAT. 

which influences the muscles and determines their contractions 
in a definite and congruous series. 

"The actions thus produced may proceed immediately 
from the impression, and in close connection with it. They 
are then termed instinctive. They may result, also, from the 
associations which the impression excites, and be governed by 
a consciousness of the end to be produced, and then they are 
called voluntary. 

Cabanis ' considers the subject of instinct with more philo- 
sophical knowledge than any writer of or before his day- As 
his views have been received with much attention, and have 
exerted a greater or less governing power over all subsequent 
inquiries in the same direction, I shall discuss them at some 
length. 

Philosophers are divided in regard to the following two 
points. Some think with Condillac that all the acts of ani- 
mals are due to reason, and are, consequently, the results of 
experience. Others contend that many of their actions are in 
no way connected with reason, and that, while all of these 
have their source in physical sensibility, they are performed 
without any other agency of the will than that which relates 
to its action as the director of their execution. These actions 
are designated instinctive. 

Some physiologists contend that sensibility is the only 
source of all organic power. Others, among whom Haller is 
first, maintain that there is another property, distinct from, 
and even independent of, sensibility, which they call irrita- 
bility. As Cabanis says, however, the dispute is mainly one 
of words. 

Within the womb of the mother animals do not, properly 
speaking, experience any sensation. As soon as they are 
born, however — when they respire, when the action of the 
external air impresses more energy on their organs, and more 
activity, more regularity, on their movements — it is not a 
simple change of habits which they experience, but a veritable 
new life which begins. From that moment appetites spring 
up which they are compelled to gratify by an irresistible in- 
ternal force. So apt, for instance, is the infant at sucking, 
that Hippocrates concluded it was impossible the knowledge 
could be acquired so soon after birth, and contended that the 

1 " Rapports du physique et du moral de l'homme," Paris, 1824, t. i, p. 77, et 
seq. 



THE ^ATUEE OF IXSTDJCT. 129 

foetus learned the necessary movements by sucking the liquor 
amnii in the mother's womb. This point I have already con- 
sidered when Darwin's views were under notice. In addition 
to what was then said, it may be observed that the foetus cer- 
tainly does not learn to breathe in its mother's womb, and that 
the necessary muscular actions toward this object are f ally as 
complex as those concerned in sucking. 

Many quadrupeds are born with their eyes shut. Such 
can only find the nipples of their mother through the senses 
of smell and touch. These faculties they exercise with great 
sureness, and kittens will frequently, when half -born, stretch 
out their necks in search of the source of their future nourish- 
ment. 

These actions, and many others which could be mentioned, 
result from internal impressions received by the young of ani- 
mals during gestation. They are not set in operation by sen- 
sations ; on the contrary, the animal is prompted by the 
internal power to employ its senses in order to accomplish its 
objects. This force, therefore, stands in lieu of the will. In 
the case of Galen's goat, already quoted, it was instinct which 
impelled the animal to use its senses. It was not instinct, but 
reason, which made it select the milk. Instinct is not, there- 
fore, the result of experience, or of reason, or of any choice 
founded on sensations. 

The line, therefore, between rational and instinctive actions 
can be closely drawn. The former, as Locke and his disciples 
have proved, are formed from distinct impressions which come 
to our minds from exterior objects through the medium of our 
senses. The latter arise from within, as the offspring of a 
force entirely independent of, and even above, the will. The 
etymology of the word "instinct" shows conclusively which 
meaning should properly be attached to it. It is formed from 
the two Greek radicals, ei>, in; and anfav, to prick. Accord- 
ing to its derivation, instinct is the product of excitations the 
stimulus to which is applied from the interior — that is to say, 
the result of impressions received from within. 

Thus, in animals generally, and in man especially, there 
are two well-defined kinds of impressions, which are the 
sources, the one of their conscious, the other of their uncon- 
scious, determinations ; and these two kinds are found, but 
in different relations to each other, in all species. 

From the foregoing brief account and running commentary 



130 INSTINCT; ITS NATURE AND SEAT. 

on Cabanis's views, it will be seen that he was fully aware of 
the true source of instinctive actions, and that he clearly dis- 
tinguished between them and those which result from mental 
processes. 

A writer, 1 whose name is not given, but who has evidently 
reflected a good deal upon the subject of instinct, and others 
of an analogous character, makes the great mistake of ascribe 
ing instinctive actions to external stimuli. Thus, he says : 
" We confess, however, that we do not see why the term in- 
stinctive should not be applied to all the actions which are 
performed in direct respondence to an external stimulus." 
And again : 2 

u We have employed the term instinctive here and else- 
where to denote much more than is included under it by many 
writers. Some have restricted it to one class of excited actions, 
some to another ; but we think that it may be applied with 
the greatest propriety to designate all those changes in the 
muscular system which are immediately excited by impres- 
sions from without, which are not respondent upon the exer- 
cise of the will, though more or less capable of being controlled 
by it, and which, if acting alone, deprive the being of the 
character of a free agent." 

This writer, though recognizing what are really instinctive 
actions, includes among them all reflex, and even voluntary, 
actions, going further in this respect than any other author 
whose views have come under my notice. In a subsequent 
article he reiterates the opinion that the actions in question 
are all performed in obedience to external stimuli. 

Dr. Alison 3 is more exact when he says : " The most cor- 
rect expression of the difference between an action prompted 
by instinct and one prompted by reason is, that in the first 
case the will acts in obedience to an impulse which is directly 
consequent upon certain sensations or emotions felt or remem- 
bered ; in the last it acts in obedience to an impulse which 
results from acts of reasoning and imagination. In a subse- 
quent paragraph, however, Dr. Alison seems disposed to in- 
clude such purely reflex operations as breathing, winking, 
coughing, sneezing, vomiting, etc., among instinctive ac- 
tions. 

1 " British and Foreign Medico-Chirurgical Review," vol. v, 1838, p. 491. 

2 Op. cit., p. 505. 

3 " Cyclopaedia of Anatomy and Physiology," vol. iii, p. 3, art. " Instinct." 



THE NATUKE OF INSTINCT. 131 

Collineau, 1 in an exceedingly philosophical treatise on the 
mind, applies the word instinct to all interior sensitive move- 
ments, intellectual, affective, and mental, be they voluntary 
or involuntary, which are exercised without knowledge of the 
nature or cause, by the being acting immediately, by virtue of 
organization and inherent disposition. 

In psychology, instinct begins everything. It is manifested 
with the first organic movements. It is, in some respects, an 
intelligence communicated with life, and which is developed, 
more or less, according to circumstances, habitudes, and the 
degree of organization. 

Instinct in man is arrested or weakened as soon as we have 
the intimate feeling or conscience of our intellectual acts, for 
this intimate feeling, this conscience, is the line of demarca- 
tion which is to stand between instinctive actions and those 
due to intelligence. This line does not actually exist in nat- 
ure ; it is only a conception of the mind ; in reality, there is 
always instinct where there is intelligence, even when this 
latter is greatly in the ascendency, and although reason, for 
the time being, causes instinct to disappear, it does not ac- 
complish its destruction. 

Before the intelligence of a being is brought into active 
existence there is a force which excites movements, which 
directs or limits them. It is an attribute of the sensibility 
already developed ; it is a providential cause which precedes 
knowledge and reason, but which retains the first place with 
animals not endowed with the organ of thought, and with 
those intelligent beings whose intellectual functions are not 
yet fully developed or sufficiently exercised. 

Instinctive dispositions extend to the moral life, and place 
bounds to an intelligence which cannot be passed without 
time and labor. Thus it is that nations, like individuals, have 
their infancy, their middle age, and their decline ; that cer- 
tain ideas, tastes, and proclivities are suitable to certain sexes, 
ages, constitutions, peoples, and climates. Instinct is the in- 
sensible and often unsuspected link which, by all points, in 
all times, and in every case, attaches individual life to general 
life. It is thus that absolute liberty, in regard to which there 
has been so much dispute, becomes impossible, for man, like 
the lower animals, enjoys free-will only within the instinctive 

1 "Analyse physiologique de Fentendement humaine," etc., Paris, 1847, p. 

37. 



132 INSTINCT; ITS NATURE AND SEAT. 

limits which are placed to his intelligence, to his affections, 
and to the agents of his mind. 

So far as individuals are concerned, instinct is not infalli- 
ble ; but, if we regard it as it is manifested in masses and 
species, we see that it never fails and never deceives. Its 
existence is inseparably attached to the organic life of the 
being. It controls and determines, with admirable certainty, 
all actions, even those which require the co-ordination of a 
large number of organs. Take, for instance, the numerous 
and complex acts performed by certain animals at the instant 
of their birth, as well as by man at all periods of his life. We 
can, indeed, say with truth that nature thinks and acts for 
us in an infinitude of ways that long observation and all the 
efforts of reason would fail in making us comprehend. 

Instinct is, then, innate ; it is present at all epochs of ex- 
istence, at all moments, while the ideas which come to us 
acquired by the senses, and which are formed by the intelli- 
gence, increase, and are rendered more perfect by exercise and 
by the various uses to which they are subjected by life. 

I have only given a very general idea of M. Collineau's 
views, and have omitted from his argument much that is in- 
teresting. I do not know where there is a more lucid expla- 
nation of the psychology of instinct than is to be found in his 
admirable volume. His conclusions in regard to the nature 
of this faculty are briefly as follows. He divides all manifes- 
tations of instinct into two classes. 

1. All spontaneous movements which, in beings endowed 
with organization and animal life, are constantly in force, 
according to the species, and more or less directly with a 
common aim of preservation, reproduction, or propagation. 

2. All acts which begin, and can even sometimes be fin- 
ished, independently of sensation, of comparison, of judgment, 
of ideas, and of reflection — that is to say, without the aid of 
the reason or the will, without imitation, without the knowl- 
edge of means by which they might be accomplished, or of 
the results to which they might lead. The word instinct is 
the indication of the unknown cause, and of the sum total of 
acts of this nature. 

Voisin, 1 though giving no precise definition of insanity, 
sets out with the observation that he will consider in his 
treatise the fundamental and primitive forces of our cerebral 
1 " Analyse de Tenteo dement humaine," etc., Paris, 1858, p. 53, et seq. 



THE NATURE OF INSTINCT. 133 

constitution. He then treats of the " instinct of generation," 
the " social instinct," the "instinct of self-defence," the "in- 
stinct of destruction," etc., showing that, in his opinion, these 
are primary faculties not acquired by sensation or experience, 
but originating with the life of the individual, and developing 
therewith. 

Leuret and Gratiolet, ' in treating of the instincts, enunciate 
views of which the following is an abstract : 

When we voluntarily perform — that is to say, with the 
knowledge of our will — certain acts, the nature or value of 
which our intelligence has not estimated, and which it has not 
prepared, these acts are not attributed to the mind, but to 
the instinct. We do not apply the term instinct to that gen- 
eral and indefinite tendency by which a simple impulsion, 
awakening a homogeneous feeling, produces a correlative act. 
That is an automatic reaction, and is not instinct. To fly from 
a sorrow that threatens us, to combat a harm that has attacked 
us, to pursue an object that arouses in us pleasing emotions, 
is to act automatically, it is true, but not instinctively. In- 
stinct is not at all a reaction produced in connection with 
exterior impressions. It is an innate tendency, which is due 
from the first moment of life to the arrangement of the organic 
mechanism, and to harmonious influences preordained with 
the world. For instance, let us suppose a clock wound up, 
and let us suppose the loom of a weaver. As soon as the 
pendulum of the one is set in motion the hands mark the 
hour ; and as soon as the hand of the workman raises the 
lever of the other the fabric begins to be made. Let us further 
suppose these machines to be gifted with a certain degree of 
consciousness and personality, the instinct of the clock will 
be to mark the hour, and that of the loom to weave tissues. 

Thus, between inanimate and animate machines there is 
but one point of difference — the one acts and is ignorant of 
what it does, the other is restrained by an overpowering prin- 
ciple of which it is conscious. Therefore, when an animal 
wishes to act, its will is directed toward the organs by which 
action is possible. No man has the instinct to fly ; no bird 
has the instinct to grasp things with its wings. The natural 
will never, therefore, exceeds the limits of possible action. 
Thus, instincts differ according to species and individuals — 

1 " Anatomie comparee du systeme nerveux considere dans ses rapports avec 
Intelligence, 1 ' Paris, 1839-'57, t. ii, p. 632. 



134 INSTINCT; ITS NATURE AND SEAT. 

that is to say, according to organization. The little duck 
which the hen has hatched seeks the water as soon as it has 
escaped from the egg, and swims without ever having been 
taught. Every being and thing, says St. Augustine, seeks 
the place which it ought to occupy in nature. One accom- 
plishes its work blindly, another mingles a little intelligence 
with its instinct, but all fulfil their destiny necessarily ; to 
man alone has been accorded the right of ambition and revolt, 
in order that the virtue of ambition should also exist. 

MM. Leuret and Gratiolet 1 thus distinctly recognize the 
difference between reflex and instinctive actions, and give a 
very clear idea of the relations which exist between instinct 
and the will. 

Muller 3 advances views similar to those of the physiolo- 
gists just quoted. He regards instinct as innate, as not excited 
by impressions made on the senses, and as being due to a de- 
terminate purpose, identical with motive organic power. 

Dr. J. W. Draper 3 has enunciated several erroneous ideas 
relative to instinct. He deems it incapable of improvement, 
and not liable to error. Both of these opinions are, as I shall 
endeavor to show hereafter, erroneous. 

Dr. Dalton 4 evidently considers it as due to impressions 
conveyed inwardly from the senses, and does not, I think, 
sufficiently discriminate between its manifestations and those 
which are of a reflex character. These errors, as we have 
seen, have been committed by several authors, and perhaps 
the majority of those who have written upon the subject 
entertain similar views. There seems to be an indisposition 
to recognize the fact that there are innate organic predispo- 
sitions born with the being exhibiting them, and predominat- 
ing over all mental and nervous powers. 

Lelut, 6 in the main, adopts the theories of Stahl relative 
to the differences between instinct and reason, the X070? — 
that is to say, the general formula for all those acts of the 
mind in the direction of the body which are vague, intermit- 

1 It should be stated that the second volume — the one embracing the remarks 
on instinct — of the joint work of these authors was written entirely by M. Gra- 
tiolet, the first by M. Leuret. 

a " Elements of Physiology." Translated by Dr. Baly, London, 1842, vol. ii, 
p. 947. 

8 " Human Physiology, Statical and Dynamical," New York, 1856, p. 603. 

4 " A Treatise on Human Physiology." 

6 " Physiologie de la pensee," etc., Paris, 1862, p. 176, et seq. 



THE NATURE OF INSTINCT. 135 

tent, and sensitive, rather than intellectual — corresponding to 
the instinct, while the Xoyio-fio^ is that state, that degree of 
intelligence, where the reason is in the ascendency. His views 
are more transcendental than philosophical, and do not evince 
much physiological research. 

Fredault * considers instinct under the term "animal impul- 
sion," as that faculty which excites sensibility and motion. 
Exterior causes, in his opinion, influence this faculty. 

Dr. McCosh 2 argues with great vigor in favor of the exist- 
ence of intuitive laws, principles, or rules, which guide the 
mind. At the same time he denies, with Locke, the existence 
of innate ideas. I am unable to distinguish between these 
intuitions of Dr. McCosh and instincts, although he makes no 
attempt to explain or account for the latter, and even alto- 
gether ignores their existence. The following quotation shows 
the character which he ascribes to intuitions, and their iden- 
tity with instincts : 

" They are native. However they have been called — natu- 
ral, innate, connate, implanted, constitutional — all these phrases 
point to the circumstance that they are not acquired by prac- 
tice, nor the result of experience, but are in the mind natu- 
rally, as constituents of its very being, and involved in its 
higher exercises. In this respect they are analogous to uni- 
versal gravitation and chemical affinity, which are not pro- 
duced in bodies as they operate, but are in the very nature of 
bodies, and the springs of their action." 

Flourens 3 recognizes three great facts — the instinct, the 
intelligence of animals, and the intelligence of man. Each of 
these has its fixed limit. The instinct acts without knowing ; 
the intelligence knows in order to act. The intelligence of 
man alone knows and is self-conscious. What an animal does 
through instinct it does without having learned how to do it ; 
what it does through the intelligence it does through expe- 
rience or instruction. He denies reason to all animals lower 
in the scale of creation than man. 

Flourens is not, I think, consistent in this latter view. 

lu Traite d' anthropologic physiologique et philosophique," Paris, 1863, p. 
425. 

2 "The Intuitions of the Mind Inductively Investigated," London, 1860, 
p. 42. 

3 " De l'instinct et Intelligence des animaux," 4ieme edition, Paris, 1861, p. 
103, et seq. 



136 INSTINCT; ITS NATURE AND SEAT. 

The example which he gives of the difference between an 
instinctive and an intelligential action shows this. I quote 
his exact language : 

" Every one has seen the garden-spider, whose web is made 
of strands radiating from a centre. I have often seen it, just 
hatched, begin to weave its web. Here instinct acts alone. 

" But if I tear the web the spider repairs it ; it repairs the 
torn part ; it does not touch the rest ; and this torn place it 
repairs as often as I tear it. 

" There is in the spider the mechanical instinct which 
makes the web, and the intelligence (the kind of intelligence 
which exists in spiders) which advises it of the torn place — of 
the place where the instinct must act." 

M. Flourens might have added that there also exists the 
reason which enables the spider to deduce from the evidence 
of its senses the conclusion that its web is torn, and that it 
may be mended by similar operations to those employed in its 
original construction. 

Lord Brougham 1 regards instinct as unchangeable, and 
does not discriminate between the instincts and the appetites. 

Darwin 2 (Charles) asserts that it is in many cases impossible 
to decide whether certain social instincts have been acquired 
by natural selection, or are the results of other instincts, or are 
simply the result of long-continued habit. The whole tenor 
of his remarks relative to instinct is to the effect that there 
was a time in the history of every species in which the in- 
stincts were different from what they are now. Some have 
been formed, others have been lost. Briefly stated, his theory 
is as follows : 

If we study the individuals of a species, we perceive that 
they present certain anatomical and physiological character- 
istics, and contain mental aptitudes or faculties, manners, or 
instincts. If, however, we go back into the remote past, and 
examine, so far as we are able, the ancestors of these individ- 
uals, we perceive that there was a period in which they did 
not possess the same anatomical and physiological character- 
istics, or the same mental faculties or instincts. The change 
has been a gradual one, but it has nevertheless been steadily 
going on. 

1 " Dialogues on Instinct," etc., London, 1844. 

J " The Descent of Man and Selection in Relation to Sex," New York, 1871. 
Also, " Origin of Species," New York, 1871. 



THE NATURE OF INSTINCT. 137 

The influence of habit, transmitted from generation to 
generation, becomes an instinct in the descendants, and to 
these influences Darwin attributes most of the instincts which 
animals possess. 

But this mode of origin, though doubtless explanatory of 
many instinctive actions performed by the lower animals and 
by man, will not suffice for others. Thus, as Carpenter J has 
pointed out, the offspring of certain of the solitary bees can 
know nothing of the construction of its nest, either from its 
own experience or from instruction communicated by its pa- 
rent, so that, when it makes a nest of the very same pattern, 
we cannot regard it as anything else than a machine, acting in 
accordance with its nervous organization. 

My own views relative to the nature of instinct have been 
indicated, to some extent, in the comments I have made on 
the opinions of other investigators. I will proceed, however, 
to state them more systematically than I have yet done. 3 

Instinct is that innate faculty which organic beings possess, 
by which they are enabled, or impelled, to perform certain 
volitional acts, without being prompted thereto by the per- 
ceptions, the intellect, or the emotions, and even in direct 
opposition thereto, which acts are preservative of the well- 
being or life of the individual, or of the species to which it 
belongs. 

There are certain qualities and circumstances connected 
with instinct which require attentive consideration. 

In the first place, instinctive acts, so far as the individual 
exhibiting them is concerned, are not the results of instruc- 
tion or experience. This is one of the most prominent points 
wherein the actions in question differ from those which pro- 
ceed from intelligence and reason, performed for a definite 
purpose. These latter are necessarily due to impressions con- 
veyed to the mind through the senses and nerves, and are, 
therefore, of eccentric origin. The former are prompted by a 
force acting altogether without the agency of intelligential 
external sensations of any kind, and are of internal origin. 

1 " Principles of Mental Physiology," London, 1874, p. 58. 

2 As certain view3 relative to instinct, published within the last few years, 
are, in some respects, similar to my own, it may be proper to state that the ideas 
here expressed were published in an article entitled "Instinct, its Nature and 
Seat," contained in the Quarterly Journal of Psychological Medicine for July, 
1867. 



138 INSTINCT; ITS NATURE AND SEAT. 

Sir James Hall, who was engaged in hatching eggs by arti- 
ficial heat, saw, on one occasion, a chicken in the act of escap- 
ing from its shell. Just as the animal succeeded, a spider ran 
along the box, and the young bird immediately darted forward, 
seized, and swallowed it. 1 In this case there necessarily could 
not have been any but an innate impulse that prompted the 
movements. And thus the new-born child does not take its 
mother's breast because it smells, or sees, or recognizes it by 
the touch, or tastes the milk, or even because it is hungry. 
The first time it takes it its movements are wholly instinctive. 
It is impelled, by a power which has no element of knowledge 
about it, to stretch out its head in search of something, it does 
not know what. When the nipple is put into its mouth it 
sucks, it does not know why. It will suck anything else, 
showing that it is not guided by the evidence of any of its 
senses ; for, if this were the case, the impression made upon 
its mind would be that of this other thing — a finger, for in- 
stance — and it would immediately stop sucking. So little has 
sensation to do with the action, that the child will even take 
nauseous mixtures without perceiving their disagreeable quali- 
ties. That hunger is not the immediately impelling force is 
very evident, from the facts that the child will suck before 
this sensation is formed, and that it will continue to do so 
after satiety is reached. 

Besides, even admitting that, in the new-born child, im- 
pressions are conveyed to its brain through its senses, and 
that thus actions are initiated, what possible connection can 
there be in its mind between the shape and softness of the 
mother's breast and the odor of milk, and the fact that, by 
sucking, its life will be maintained? Is it not self-evident 
that the senses can only lead to intellectual processes, and to 
these solely as the results of experience. For instance, there 
is nothing about a lighted cigar that would lead a young 
puppy, a priori, to a conclusion in regard to the unpleasant 
consequences of smelling it. When, however, he has once 
made the attempt, with all the simplicity of his confiding 
nature, has burnt his nose and been stifled with the smoke, 
he has acquired knowledge, and has formed an idea in regard 
to a lighted cigar which never deserts him. It is, of course, 
impossible that a new-born child sucks at first because of any 

1 " The Ganglionic Nervous System," etc., by Dr. James George Davey, 
London, 1858, p. 145. 



THE NATURE OF INSTINCT. 139 

instruction it may have received, or experience it may have 
acquired — though, as we have seen, it has been asserted that 
it learns to suck by practicing on the liquor amnii in its 
mother's womb — and, its mind being more immature than 
that of a young puppy, more frequent instinctive efforts are 
necessary before it becomes capable of forming an idea of a 
necessary relation between the mother's milk and its own sen- 
sation of hunger. 

The action is, therefore, initiated through instinct ; but, 
with each repetition, two other forces are developed, the one 
reflex, by virtue of which, whenever an object is placed in the 
infant's mouth, the lips are closed upon it, and sucking move- 
ments begun ; just as the eyes are closed when motions, as if 
to strike, are made before them, or as coughing takes place 
when an irritating substance touches the larynx ; the other, 
based upon the relation of cause and effect, a purely reasoning 
process carried on by the child's brain. As this latter becomes 
more completely developed, the two others are gradually ex- 
tinguished, until finally the action is performed in direct 
accordance with the intellect, and in obedience to the will. 

From what has been said, the reader will perceive that my 
faith in the power of infantile sensational impressions is not 
great. It is well known to physiologists that none of the 
senses are even tolerably developed in the new-born infant. 
The sight, the hearing, the taste, and the smell, are almost 
nothing, and the sense of touch is scarcely apparent. The 
ability to feel pain, in a certain general way, undoubtedly 
exists, and this the infant probably has even in the womb. 
It is unphilosophical, therefore, to assume, as have some 
authors, that the new-born of man comes into the world with 
its senses in full operation. 

It is assumed by some authors that the instinct is incapable 
of improvement. There is an ambiguity about this expression 
which is liable to lead to erroneous ideas. It is true that the 
instinct of any one individual being cannot be improved. 
The only means by which such an attempt could possibly be 
made would be by the senses, and then reason, not instinct, 
would be developed. The one would take the place of the 
other. But instances of the education of the instinct through 
a series of generations are common enough. For instance, 
navigators relate that the duck and other water-birds, of those 
regions which are not often visited by man, evince, at first, no 



140 INSTINCT; ITS NATUKE AND SEAT. 

instinctive fear at his approach. It was, probably, a natural 
condition of these and many other animals not to be afraid of 
man. But, as man knocked them over with his oars, and shot 
them with his guns, a force began to be created which, acting 
gradually upon successive generations, has become innate, 
and thus the young shows from the first a fear of man. With 
the domestic animals, however, this force has been lost, for, 
during many centuries, an opposite education has been acting 
upon them. Again, the young of a pair of wild quails run 
away into the thicket as soon as they have broken the eggs. 
In such a case there has not been enough time for the natural 
instinct to become obliterated, but in three or four generations 
it becomes entirely extinguished. With many varieties of 
dogs the instincts have been wonderfully developed by long- 
continued instruction and experience. It would appear, there- 
fore, that the intelligence of former generations becomes con- 
verted into instinct in the descendants. 

In man, instincts have been developed in accordance with 
the circumstances in which he has been placed as he has in- 
habited different parts of the world. This is especially notice- 
able as regards certain instinctive emotions which are not felt 
by him in the savage state, but which have become promi- 
nent through the power of civilization and refinement, acting 
through many successive generations. I have seen an infant 
a year old shudder with disgust at the sight of a hair in its 
porridge. The universal use of the right hand in preference 
to the left is evidently the result of education and habit con- 
tinued through centuries, and leading to the increased devel- 
opment of the left side of the brain over the right. 

Instincts can be lost in man, and even more readily than in 
the lower animals. In illustration of this assertion, it is only 
necessary to recollect that in the new-born infant, if the breast 
be withheld for only a few hours, the instinct which prompts 
to sucking is lost, and the child refuses the breast. 

A curious circumstance related by Cabanis 1 is applicable to 
the question under consideration. He says : "In my district 
of country, and in several others which border upon it, when 
hatching hens are needed, it is customary to practice a singular 
procedure which is worthy of notice. A capon is taken, the 
feathers are stripped from the breast, and it is rubbed with 
nettles and vinegar. In the state of local irritation which this 

1 " Pwapports du physique et du morale de rhomme," Paris, 1824, p. 215. 



THE NATUKE OF INSTINCT. 141 

operation induces, the capon is placed on the eggs which are 
to be hatched. At first he remains there mechanically, and, in 
order to assnage the pain which he experiences. Very soon, 
however, there is established within him a series of unaccus- 
tomed but agreeable impressions, which have the effect of at- 
tracting him to the eggs for the time necessary to bring the 
young to a state of maturity, and which also produce in him 
a species of factitious maternal love which lasts, as in the hen, 
as long as the young have any need of his cares. Cocks can- 
not be thus used ; they have an instinct which leads them in 
another direction." 

Here we might almost say that an instinct is created in 
place of the one abolished. It is one, however, which, from 
its nature and the attendant circumstances, cannot be propa- 
gated. But, if cocks could be employed for the purpose in 
question, say by the method mentioned, I have no doubt that 
in time the instinct would become permanently created in 
them. 'No sufficient efforts have been made in this direction. 
It is well known that instincts may be entirely destroyed by 
the action of other instincts more powerful. In the swallow 
and other migratory birds the instinct to depart when the 
season arrives is so strong that the parental instinct, strong as 
it is, is overcome, and they often go, leaving their young to 
die from neglect. Here we have an instance of an instinct of 
supreme importance to the preservation of the species over- 
coming another of less importance. And in regard to the im- 
provement or alteration of the instinct in the lower animals, it 
must be borne in mind that attempts in that direction by man 
have not been many. Who can say what would be the result 
if systematic efforts had been made during several hundred 
years to change the instinct of bees which prompts them to 
construct their cells of a hexagonal form % Doubtless, if left 
alone, they will never deviate in the slightest degree from the 
plan which, so far as we know, they have always followed. 
There is no reason why they should. But, if the formation of 
hexagonal cells could be rendered impossible for bees during 
many successive generations, I believe the instinct to make 
them of that shape would be lost. JSTo instinct is stronger 
than that of the salmon to return to the place where it was 
spawned. It will beat itself to death in its frantic leaps to 
surmount obstacles placed in its way in the river from which 
it emigrated. But we know that impediments of various 



142 INSTINCT; ITS NATURE AND SEAT. 

kinds have driven them from streams they once frequented 
to others where no obstacles exist. 

It is incorrect, also, to contend for the unerring character 
of instinct. Instances of its aberration are very common. The 
beaver, which proceeds to construct a dam across a room in 
which it may be confined, commits a very serious instinctive 
error. So does the house-fly, when, hour after hour, it dashes 
itself against a pane of glass in a window in its efforts to 
escape toward the light, never learning by experience and 
intelligence that its attempts are in vain. 

In the placental animals lower than man, instinct prompts 
to the division of the umbilical cord with the teeth. In several 
species, as the pig and the dog, this impulse is occasionally 
perverted, and they eat their own young. 

In their original state, the horse and the cow eat the pla- 
centa. This has been prevented in some countries by the 
organ being removed as soon as it is born, and the instinct 
is lost ; but in Sweden the mare is allowed its full liberty in 
this respect, and in that country the placenta continues to be 
eaten. 

In man, the maternal instinct is liable to perversion, and 
the instinctive love of the mother for her offspring is some- 
times turned to indifference and hatred. 

In my definition of instinct I have been careful to use the 
term " organic beings," instead of animals. I did this because 
I am very sure that plants have instinct ; that is, a force, co-ex- 
istent with their growth and implanted originally in the seed, 
which impels them to the performance of actions calculated 
to preserve their existence or secure their well-being. We 
see this power manifested in those plants which shoot out 
tendrils in search of a support, in those which send their 
radicles deep into the earth in dry weather, and in those 
which open and close their flowers with the rising and setting 
of the sun. These last-named acts are not the consequence of 
any physical influence of the light or heat of the sun's rays, 
for they are performed when both are excluded. The sun- 
flower turns its face to the sun at all periods of the day. It 
does the same thing, as I have ascertained, when it is entirely 
covered by an India-rubber tent. There is here another in- 
stance of an error of instinct. 

It would therefore be unphysiological to deny them the 
possession of the faculty under consideration — a faculty 



THE NATURE OF INSTINCT. 143 

which stands them in place of reason, which they probably 
have not. So far as I can perceive, the instinct of plants 
differs in no essential respect from that of animals. Its 
manifestations are, of conrse, very different. 

As to the essential nature of instinct, it is a fact as much 
as the mind is a fact. It differs in organic beings in degree 
and kind, as does the mind. It is implanted in all beings 
from their beginning, and is a necessary principle of their 
organization. But, the greater the degree of mental develop- 
ment, the less prominent is the instinct, till, when we reach 
man, it is lower than in any other animal in which its mani- 
festations have been studied. 



CHAPTER II. 

THE SEAT OF IJSTIXCT. 

The brain of man is more highly developed than that of 
any other animal ; he has reasoning powers in excess of those 
possessed by any other living being ; his mind governs the 
world, and, not content with that, seeks for knowledge of 
those spheres beyond that in which he dwells. But, with all 
this, he is surpassed by almost every other animal in the 
ability to perform acts instinctively — by beings, in fact, whose 
brains are infinitely less perfect than his, and by others which 
have no organs corresponding to a brain. 

If the instinct of man were seated in his brain, he would 
doubtless exhibit a development of this faculty so great as to 
place him on that score as high as he now stands as regards 
his mind. 

Going back, for the present, to some of the lower animals, 
we find that we are able, by certain experimental procedures, 
to settle some points relative to the seat of instinct with abso- 
lute certainty. 

1. It does not reside exclusively in the brain. The 
brain of many animals, especially of those belonging to the 
class of reptiles, can be removed without the animal suffering 
any very considerable immediate inconvenience. In such 
cases the instinct remains unimpaired. 1 Thus Maine de Biran 

1 In the president's address delivered before the New York Neurological So- 
ciety, May 3, 1875, entitled," The Brain not the Sole Organ of the Mind, 1 ' I have 



14A INSTINCT; ITS NATURE AND SEAT. 

states that, according to Perrault, a viper, the head of which 
had been cut off, moved without deviation to its hole in the 
wall. It is impossible that the viper could have seen, heard, 
smelt, tasted, or felt the wall. It could only have gone toward 
it instinctively, through the action of a force not residing in 
its brain, and altogether independent of perception. 

It is an instinct in certain animals to swim when placed 
in water. I removed the entire brain of a frog, and, after wait- 
ing a few minutes for the animal to recover from the shock 
of the operation, I placed it in a tub of water. It imme- 
diately began to swim. I held my hand so that the animal's 
head would come in contact with it, and thus further progress 
be prevented. Continued efforts to swim were made for a few 
seconds, and then ceased. Removing my hand, the animal 
again swam. 

Of such movements, Yulpian says that when the frog is 
placed in water an excitation is produced over the entire 
surface of the body in contact with the water ; this excitation 
provokes the mechanism of swimming, and this mechanism 
ceases to act as soon as the cause of the excitation has disap- 
peared by the removal of the frog from the water. If this 
were a true explanation, the movements of swimming would 
certainly be continued, notwithstanding the interposition of 
an obstacle ; but, as we have seen, they are arrested. Onimus 
shows very conclusively, and I have verified his experiments, 
that Vulpian's explanation is not correct ; for, as he declares, 
with frogs without brains placed in water, and from which 
the skin has been entirely removed, the movements of swim- 
ming are continued when they are again placed in the water, 
which proves that the excitation of the cutaneous surface is 
not the cause of the movements. 

I have repeatedly performed similar experiments with 
turtles of various kinds, and lately with water-snakes. In all 
these cases the whole brain was removed from the cranium, 
yet the animals did not wobble about aimlessly in the water, 
but swam straight out into the stream or pond apparently 
with as complete a purpose to escape as though they still 

shown that certain faculties of the miod are seated in the spinal cord. The 
subject of Instinct was not considered, but some of the movements mentioned 
then will be seen to have been purely instinctive. I have made use of these 
illustrations with others not therein contained in the present chapter. See 
Journal of Nervous and Mental Disease, January, 1876, for the paper in full. 



THE SEAT OF INSTINCT. 145 

possessed the full degree of consciousness of the unmutilated 
animals. 

Such experiments show, beyond a doubt, that perception 
and volition are not seated exclusively in the brain, and 
thus that instinct is not indissolubly connected with that 
organ. 

It is impossible to make similar investigations in the 
higher animals with such definite results as those obtained 
with reptiles, but we may call to mind the fact familiar to all 
physiologists, and to which reference has been made in an 
earlier part of this work, of the behavior of a pigeon the 
brain of which had been removed. Though in such a case 
most of the actions are the result of perception, yet some, as 
for instance the act of flying when it is thrown into the air, 
are purely instinctive. But nature has performed many ex- 
periments for us, and these not only on the lower animals, but 
also on man, which teach us conclusively that even in him 
instinct does not reside in the brain. They show, too, that 
certain faculties of the mind are not confined to that organ ; 
but with that fact we need not at present concern ourselves. 

In certain monsters born without a brain, or with impor 
tant parts of this organ absent, we have interesting examples 
of the persistence of instinct. Syme x describes one of these 
beings which lived for six months. Though very feeble, it 
had the faculty of sucking, and the several functions of the 
body appeared to be well performed. Its eye s clearly perceived 
the light, and during the night it cried if the candle was al- 
lowed to go out. After death the cranium was opened, and 
there was found to be an entire absence of the cerebrum, the 
place of which was occupied by a quantity of serous fluid con- 
tained in the arachnoid. The cerebellum and pons Varolii 
were present. 

Panizza, 2 of Pavia, reports the case of a male infant which 
lived eighteen hours. Respiration was established, but the 
child did not cry. Xevertheless, it was not insensible. Light 
impressed the eyes, for the pupils reacted to its influence. A 
bitter juice put into its mouth was immediately rejected. Loud 

1 Edinburgh Medical and Surgical Journal, vol. xxiv, p. 295. This monster 
belonged to the genus Thlipsencephalus of Geoffroy Saint-Hilaire, so far as I can 
determine. 

2 Cited by Gintrac, "Maladies de Tappareil nerveux," Paris, 1867, t. i, p. 51. 
This was also probably a ease of thlipsencephalus. 

10 



146 INSTINCT; ITS NATUKE AND SEAT. 

noises caused movements of the body. On post-mortem ex- 
amination there was found no vestige of either the cerebrum 
or cerebellum, but the medulla oblongata and pons Varolii 
existed. There were no olfactory nerves, the optic nerves 
were atrophied, and the third and fourth nerves were want- 
ing. All the other cranial nerves were present. 

It is not stated of this instance that sucking was or was 
not performed, but most of the movements mentioned were 
evidently reflex. The rejection of a bitter juice from the 
mouth was, however, probably instinctive, as was also the 
reaction of the pupils to light. This latter could not have 
been a reflex movement, as the optic nerves were atrophied, 
and there was no way, therefore, by which a reflex action 
could have been carried out. 

Ollivier d' Angers 1 describes a monster of the female sex 
which lived twenty hours. It cried, and could suck and swal- 
low. There was no brain, but the spinal cord and medulla 
oblongata were well developed. 

Saviard 2 relates the particulars of a case in which there 
were no cerebrum, cerebellum, or any other intra-cranial gan- 
glion. The spinal cord began as a little red tumor on a level 
with the foramen magnum. Yet this being opened and shut 
its eyes, cried, sucked, and even ate broth. It lived four 
days. Some of these movements were reflex, but others were 
clearly instinctive and adapted to the preservation of life. 

Dubois, 3 on the authority of Professor Lallemand, of Mont- 
pellier, cites the case of a foetus, born at full term, in which 
the cerebrum and cerebellum were entirely absent. There 
were no ganglionic bodies within the cranium but the me- 
dulla oblongata and the pons Varolii. This foetus lived three 
days ; during all this time it uttered cries, exercised suc- 
tion movements when anything was put into its mouth, and 
moved the limbs. It was nourished with milk and sweetened 
water, for no nurse would give it her breast. Dubois cites an- 
other case, on the authority of Spessa 4 of Treviso, of a child 

1 " Maladies de la moelle epiniere," Paris, 1837, t. i, p. 179. 

2 Cited by Gintrac, op. cit., p. 46. Isidore Geoffroy Saint-Hilaire classes this 
monster as a nosencephalus. " Histoire generale et particuliere des anomalies 
chez 1'homme et les ammanx," Bruxelles, 1837, t. ii, p. 235. 

8U De Finstinct; ou des determinations instinctives. Memoires de l'acade- 
mie royale de medicine," t. ii, 1833, p. 304. Probably a thlypsencephalus. ■ 

4 Isidore Geoffroy Saint-Hilaire, while classing this case among thlipsen. 
cephali, questions some of the anatomical details. Op. cit., p. 252. 



THE SEAT OF INSTINCT. 147 

born without cerebrum, cerebellum, or medulla oblongata, 
and which lived eleven hours. It cried, breathed, and moved 
its limbs, but it did not suck. It is difficult to say of this 
case to what extent its movements were instinctive, and to 
what extent reflex. 

. But all these instances, as well as the experiments referred 
to as having been performed on lower animals, show that in- 
stinct does not reside in the brain. 

2. It is seated exclusively in the medulla oblongata, or in 
the spinal cord, or in both these organs. The observations 
made and experiments cited under the immediately preceding 
head, apparently lead to the conclusion that the medulla ob- 
longata, or spinal cord, or both these organs, may be the seat 
of instinct, and further inquiry shows that this view is as cor- 
rect as that which associates the brain with the mind. It is 
well known to naturalists that the male frog, in his sexual 
relations with the female, remains in contact with her for 
sometimes as long as a month. So powerful is this instinct, 
and at the same time occasionally so blind, that he will attach 
himself during the spawning season to anything that is placed 
between his forelegs — the thumb of the observer, for instance — 
and is sometimes found adhering strongly to his natural enemy, 
the pike. Mr. H. Bell x states that this instinct of adhesion is 
in fact sometimes fatal to its legitimate object, as he has taken 
from the water a large conglomeration of male frogs, amount- 
ing to twelve or more, with one solitary female in the middle 
of the group dead and putrid, and even some of the males 
toward the centre of the collection pressed into an almost life- 
less and shapeless mass. 

I have repeatedly cut off the tuberculous thumbs of the 
male frog, which in the spring take on an increased develop- 
ment ; and, though the ability to grasp the female is very con- 
siderably lessened thereby, attempts in that direction are 
made, and with more or less success. Indeed, the ablation of 
both forelegs does not prevent attempts at the sexual em- 
brace. 

These facts demonstrate the intensely powerful character 
of the instinct of generation in these animals. 

Now let us see if we can ascertain, by experiments upon 
them, where this instinct resides. 

1 "The Cyclopaedia of Anatomy and Physiology," vol. i, p. 105, art. "Am- 
phibia." 



14:8 INSTINCT; ITS NATUKE AND SEAT. 

I have many times cut off the head of the male frog while 
he was in sexual contact with the female, but never with the 
effect of causing him to relax his hold till several days had 
elapsed. If care be taken, by placing them in wet moss, to 
keep the skin from becoming dry, and to maintain a com- 
paratively low temperature, frogs can be kept alive for over 
a week after their heads are cut off, and during all this time ; 
the male remains in contact with the female. Indeed, if he be 
forcibly separated from her, and then again brought into con- 
tact with her, he at once resumes his former position. In like 
manner he will attach himself to any other body that may be 
placed in contact with his abdomen. 

But, if the amputation of the head be made so as to in- 
clude the medulla oblongata, the force of the instinct is very 
much lessened, and is much sooner abolished than when only 
the head is removed. The animal will still grasp the thumb, 
or any substance placed in contact with the under surface of 
his body, but his hold is not so vigorous, and in a few min- 
utes it is relaxed. 

If the head of a frog in the spawning season be cut off, so 
as not to include the medulla oblongata, and then, taking care 
not to injure this latter organ, the spinal cord be broken up 
with a stylet, the instinct in question is not yet abolished. 
The female is still grasped, and the hold not immediately re- 
laxed if the operations be performed on a male frog attached 
to the female. 

If the head be cut off, and the medulla oblongata and spi- 
nal cord be broken up, the grasp is immediately loosened, 
and cannot again be taken. 

And if the head be suffered to remain undisturbed, and 
the medulla oblongata and spinal cord be destroyed, the in- 
stinct of generation is at once abolished ; the male relaxes his 
grasp of the female, and cannot be made to resume it. 

In amyelencephalic monsters ' of the human species there is 
neither brain nor spinal cord. There is no authentic instance 
on record of any one of these creatures being possessed of the 

1 Geoffroy Saint-Hilaire (a) and his son (5) gave the title anencephalic to those 
monsters in whom there is neither brain nor spinal cord, making two genera of 
them. Beclard proposes the name am yeleD cephalic (without brain and spinal 
cord), as more correctly describing these monstors. 

(a) "Philosophic anatomique des monstruosites huraaines," Paris, 1822. 

(b) Op. cit. 



THE SEAT OF INSTINCT. 149 

ability to perforin any instinctive movement such as that of 
sucking. The presence in them of a sympathetic system of 
nerves is sufficient to carry on during their intra-uterine life 
the several organic functions of the body, and to enable them 
to live for a few hours after birth, the heart beating and the 
respiration being performed, though in a sluggish manner. 
As Isidore Greoffroy Saint-Hilaire 1 remarks, the majority of 
them are, however, born dead, or only survive a few minutes, 
or at most a few hours. And I think it may be positively as- 
serted with Dubois a that no human being born without brain 
and spinal cord — that is, an amyelencephalic monster — ever 
made the least movement either voluntary or instinctive. Re- 
flex actions, and those of organic life, such as the pulsation 
of the heart and the peristaltic motions of the intestines, are 
possible for a short time ; but so they are when these organs 
have been entirely removed from the body. 

Another fact tending to show that instinct does not reside 
in the brain is the fact that it exists in its highest state, in 
contradistinction to mind, in those animals that have the 
spinal cord most largely developed. Thus, in the alligator, in 
which in an animal ten feet or more in length the brain 
weighs only a fraction of an ounce, the spinal cord is of com- 
paratively great size. In the young of this reptile, as I have 
repeatedly seen in Florida, the instinct of self-defence is so 
early manifested, and is so strong, that they place themselves 
in an attitude of attack immediately on escaping from the 
egg, if they be poked at with a stick. Dr. John Davy has ob- 
served a like circumstance. 

In microcephali and other human idiots the instincts are 
sometimes exceedingly strong, and remain so through life. I 
have already referred to the instance of one of these creatures, 
an adult woman holding a rag-baby in her arms as though it 
were a child, and in whom the maternal instinct must have 
been strong, and entirely uncontrolled by the intellect. Some 
idiots also evince a great instinctive talent for music, and for 
arithmetical calculations, which, although capable of develop- 
ment, as are other instincts, are nevertheless innate. 

From these facts, and many others which might be ad- 
duced in a work specially directed to the consideration of the 
many interesting points involved, I think it may be concluded 
that instinct has at least its chief if not its only seat in the 

1 Op. cit., p. 26T. *0p. cit., p. 312. 



150 INSTINCT; ITS NATURE AND SEAT. 

medulla oblongata and spinal cord. It is possible that the 
cerebrum, the cerebellum, and the pons Varolii have some in- 
fluence in strengthening the faculty, but this is not essential, 
and its exercise is not a mental operation. 

In the consideration of the subject of insanity I shall have 
to make many allusions to instinct and its manifestations in 
the insane, and till then I reserve the further consideration of 
the question. 



SECTION III. 
SLEEP. 



The connections of sleep with insanity are so intimate and 
numerous that the consideration of this important function in 
some of its normal and abnormal relations cannot fail to aid 
us in the study of the aberrations of the human mind. The 
causes of sleep, when thoroughly studied, will be found to 
have a distinct bearing on the therapeutics of wakefulness 
and of insanity. The state of the mind during sleep is analo- 
gous in some respects to that which exists in some forms of 
lunacy. Dreams, both healthy and morbid, are sometimes the 
starting-point of insanity, and often play an important part in 
its clinical history. Wakefulness is frequently either the 
obvious cause of mental alienation, or the first sign that the 
mind is beginning to waver from its normal standards ; and the 
pathology of this condition throws more light on the pathol- 
ogy of the subsequent state of mental darkness into which 
the individual passes. I am very sure, therefore, that, in ask- 
ing the attention of the reader to the chapters in this section, 
I am rendering a service both to him and the unfortunate per- 
sons who may come under his medical charge. 



CHAPTER I. 

TEE CAUSES OF SLEEP. 



The exciting cause of natural and periodic sleep is un- 
doubtedly to be found in the fact that the brain at stated 
times requires repose, in order that the cerebral substance 
which has been decomposed by mental and nervous action 



152 SLEEP. 

may be replaced by new material. There are other exciting 
causes than this, however, for sleep is not always induced by 
ordinary or natural influences acting periodically. There are 
many others, which within the strict limits of health may 
cause such a condition of the brain as to produce sleep. 

Authors, in considering sleep, have not always drawn the 
proper distinction between the exciting and the immediate 
cause. Thus Macario, 1 in alluding to the alleged causes of 
sleep, says : 

" Among physiologists some attribute it to a congestion of 
blood in the brain ; others to a directly opposite cause — that 
is, to a diminished afflux of blood to this organ ; some ascribe 
it to a loss of nervous fluid, others to a flow of this fluid back 
to its source ; others again find the cause in the cessation of 
the motion of the cerebral fibres, or rather in a partial motion 
in these fibres. Here I stop, for I could not, even if I wished, 
mention all the theories which have prevailed relative to this 
subject. I will only add that, in my opinion, the most prob- 
able proximate and immediate cause appears to be feebleness. 
What seems to prove this view is the fact that exhaustive hot 
baths, heat, fatigue, too great mental application, are among 
the means which produce sleep." 

Undoubtedly the influences mentioned by Macario, and 
many others which he might have cited, lead to sleep. They 
do so through the medium of the nervous system, causing a 
certain change to take place in the physical condition of the 
brain. We constantly see instances of this transmission of 
impressions and the production of palpable effects. Under 
the influence of fatigue, the countenance becomes pale ; 
through the actions of certain emotions, blushing takes place. 
When we are anxious, or suffering, or engaged in intense 
thought, the perspiration comes out in big drops on our 
brow ; danger makes some men tremble, grief causes tears to 
flow. Many other examples will suggest themselves to the 
reader. It is surely, therefore, no assumption to say that 
certain mental or physical influences are capable of inducing 
such an alteration in the state of the brain as necessarily to 
cause sleep. These influences or exciting causes I propose to 
consider in detail, after having given my views relative to the 
condition of the brain which immediately produces sleep. 

It is well established as regards other viscera, that during 

1 " Du sorameil, des reves et du somnambulisme," etc., Lyon, 1857, p. 14. 



THE CAUSES OF SLEEP. 153 

a condition of activity there is more blood in their tissues than 
while they are at rest. It is strange, therefore, that, relative 
to the brain, the contrary doctrine should have prevailed so 
long, and that even now, after the subject has been so well 
elucidated by exact observation, it should be the generally 
received opinion that during sleep the cerebral tissues are in a 
state approaching congestion. Thus Dr. Marshall Hall, 1 while 
contending for this view, also advances the theory that there 
is a special set of muscles, the duty of which is, by assuming 
a condition of tonic contraction, so to compress certain veins 
as to prevent the return of the blood from the heart. 

Dr. Carpenter a is of the opinion that the first cause of sleep 
in order of importance is the pressure exerted by distended 
blood-vessels upon the encephalon. 

Sir Henry Holland 3 declares that a "degree of pressure is 
essential to perfect and uniform sleep." 

Dr. Dickson 4 regards an increased determination of blood 
to the cerebral mass, and its consequent congestion in the 
larger vessels of the brain, as necessary to the induction of 
sleep. 

In his very excellent work on Epilepsy, Dr. Sieveking 5 says : 

" Whether or not there is actually an increase in the 
amount of blood in the brain during sleep, and whether, as 
has been suggested, the choroid plexuses become turgid or 
not, we are unable to affirm otherwise than hypothetically ; 
the evidence is more in favor of cerebral congestion than of 
the opposite condition inducing sleep — evidence supplied by 
physiology and pathology." Dr. Sieveking does not, how- 
ever, state what this evidence is. 

Barthez 6 is of the opinion that during sleep there is a gen- 
eral plethora of the smaller blood-vessels of the whole body. 
He does not appear to have any definite views relative to the 
condition of the cerebral circulation. 

Cabanis 7 declares that as soon as the necessity for sleep 

1 " Observations in Medicine," second series, p. 27. 

3 "Cyclopaedia of Anatomy and Physiology," art. "Sleep," vol. iv, part i, 
p. 681. 

3 "Chapters on Mental Physiology," London, i852, p. 105. 

4 "Essays on Life, Sleep, Pain," etc., Philadelphia, 1852, pp. 63, 64. 

6 "Epilepsy and Epileptiform Seizures," London, 1858, p. 123. 

8 "Nouveaux elements de la science de l'homme," 3me edition, Paris, 1858, 
vol. ii, p. 7, et seq. 

7 "Rapports du physique et du morale de rhomme," Paris, 1824, p. 379. 



154 SLEEP. 

is experienced there is an increased flow of blood to the 
brain. 

To come to more popnlar books than those from which we 
have quoted, we find Mr. Lewes, 1 when speaking of the causes 
of sleep, asserting that "it is caused by fatigue, because one 
of the natural consequences of continued action is a slight 
congestion ; and it is the congestion which produces sleep. 
Of this there are many proofs." Mr. Lewes omits to specify 
these proofs. 

Macnish 3 holds the view that sleep is due to a determination 
of blood to the head. 

That a similar opinion has prevailed from very ancient 
times it would be easy to show. I do not, however, propose 
to bring forward any further citations on this point, except 
the following, from a curious old black-letter book now before 
me, in which the views expressed, though obscure, are, perhaps, 
as intelligible as many met with in books of our own day : 

"And the holy scripture in sundrie places doth call death 
by the name of sleepe, which is meant in respect of the resur- 
rection ; for, as after sleepe we hope to wake, so after death 
we hope to rise againe. But that definition which Paulus 
iEgineta maketh of sleepe, in my judgment, is most perfect 
where he saith : Sleepe is the rest of the pores animall, pro- 
ceeding of some profitable humour moistening the braine. 
For here is shewed by what means sleepe is caused ; that is, 
by vapours and fumes rising from the stomache to the head, 
where through coldness of the braine they being congealed, 
doe stop the conduites and waies of the senses, and so procure 
sleepe, which thing may plainly be perceived hereby ; for that 
immediately after meate we are most prone to sleepe, because 
then the vapours ascende most abundantly to the braine, and 
such things as be most vaporous do most dispose to sleepe, as 
wine, milke, and such like." s 

The theory that sleep is due directly to pressure of blood- 
vessels, filled to repletion, upon the cerebral tissues, doubtless 
originated in the fact that a comatose condition may be thus 
induced. This fact has long been known. Servetus, among 

x " The Physiology of Common Life," New York, 1860, vol. ii, p. 305. 

2 "Philosophy of Sleep," second edition, 1850, p. 5. 

3 " The Haven of Health, chiefly made for the comfort of Students, and con- 
sequently for all those that have a care for their health," etc. By Thomas Cogan, 
Master of Arts and Bachelor of Physic, London, 1612, p. 332. 



THE CAUSES OF SLEEP. 155 

other physiological truths, distinctly announces it in his 
" Christianismi Restitutio," when he says : 

" Et quando mntriculi ita opplentur pituita, ut arterice 
ipsce choroidis ea immergantur, tunc subito generatur appo- 
plexia" 

Perhaps the theory which prevails at present — of sleep 
being due to the pressure of distended blood-vessels upon 
the choroid plexus — is derived from these words of Ser- 
vetus. 

That stupor may be produced by pressure upon the brain 
admits of no doubt. It is familiarly known to physicians, 
surgeons, and physiologists ; the two former meet with in- 
stances due to pathological causes every day, and the latter 
bring it on at will in their laboratories. But this form of 
coma and sleep are by no means identical. On the contrary, 
the chief point of resemblance between the two consists in the 
fact that both are accompanied by a loss of volition. It is 
true, we may often arrive at a correct idea of a physiological 
process from determining the causes and phenomena of its 
pathological variations, but such a course is always liable to 
lead to great errors, and should be conducted with every 
possible precaution. In the matter under consideration it is 
especially of doubtful propriety, for the reason stated, that 
coma is not to be regarded as a modification of sleep, but as a 
distinct morbid condition. Sir T. C. Morgan, 1 in alluding to 
the fact that sleep has been ascribed to a congested state of 
the brain, for the reason that in apoplectic stupor the blood- 
vessels of that organ are abnormally distended, objects to the 
theory, on the ground that it assimilates a dangerous malady 
to a natural and beneficial process. He states (what was true 
at the time he wrote) that the condition of the circulation 
through the brain, during sleep, is wholly unknown. 

It is important to understand clearly the difference be- 
tween stupor and sleep, and it is very certain that the dis- 
tinction is not always made by physicians ; yet the causes of 
the two conditions have almost nothing in common, and the 
phenomena of each are even more distinct. 

1. In the first place, stupor never occurs in the healthy 
individual, while sleep is a necessity of life. 

2. It is easy to awaken a person from sleep, while it is 
often impossible to arouse him from stupor. 

1 "Sketches of the Philosophy of Life," London, 1819, p. 262. 



156 SLEEP. 

3. In sleep the mind may be active, in stupor it is as it 
were dead. 

4. Pressure upon the brain, intense congestion of its ves- 
sels, the circulation of poisoned blood through its substance, 
cause stupor, but do not induce sleep. For the production of 
the latter condition a diminished supply of blood to the brain, 
as will be fully shown hereafter, is necessary. 

Perhaps no one agent so distinctly points out the differ- 
ence between sleep and stupor as opium and its several prepa- 
rations. A small dose of this medicine acting as a stimulant 
increases the activity of the cerebral circulation, and excites 
a corresponding increase in the rapidity and brilliancy of our 
thoughts. A larger dose lessens the amount of blood in the 
brain and induces sleep. A very large dose sometimes dimin- 
ishes the power of the whole nervous system, lessens the ac- 
tivity of the respiratory function, and hence allows blood 
which has not been properly subjected to the influence of the 
oxygen of the atmosphere to circulate through the vessels of 
the brain. There is nothing in the opium itself which pro- 
duces excitement, sleep, or stupor, by any direct action upon 
the brain. All its effects are due to its influence on the heart 
and blood-vessels, through the medium, however, of the ner- 
vous system. This point can be made plainer by adducing the 
results of some experiments which I have lately performed. 

Experiment. — I placed three dogs of about the same size 
under the influence of chloroform, and removed from each a 
portion of the upper surface of the skull an inch square. The 
dura mater was also removed, and the brain exposed. After 
the effects of the chloroform had passed off — some three hours 
subsequent to the operation — I administered to number one 
the fourth of a grain of opium, to number two a grain, and to 
number three two grains. The brain of each was at the time 
in a perfectly natural condition. 

At first the circulation of the blood in the brain was ren- 
dered more active, and the respiration became more hurried. 
The blood-vessels, as seen through the openings in the skulls, 
were fuller and redder than before the opium was given, and 
the brain of each animal rose through the hole in the cranium. 
Very soon, however, the uniformity which prevailed in these 
respects was destroyed. In number one the vessels remained 
moderately distended and florid for almost an hour, and then 
the brain slowly regained its ordinary appearance. In num- 



THE CAUSES OF SLEEP. 157 

ber two the active congestion passed off in less than half an 
hour, and was succeeded by a condition of very decided 
shrinking, the surface of the brain having fallen below the 
surface of the skull, and become pale. As these changes 
supervened, the animal gradually sank into a sound sleep, 
from which it could easily be awakened. In number three 
the surface of the brain became dark, almost black, from the 
circulation of blood containing a superabundance of carbon ; 
and, owing to diminished action of the heart and vessels, it 
sank below the level of the opening, showing, therefore, a 
diminished amount of blood in its tissue. At the same time 
the number of respirations per minute fell from 26 to 14, and 
they were much weaker than before. A condition of com- 
plete stupor was also induced from which the animal could 
not be aroused. It persisted for two hours. During its con- 
tinuance, sensation of all kind was abolished, and the power 
of motion was altogether lost. 

It might be supposed that the conditions present in num- 
bers two and three differed only in degree. That this was 
not the case is shown by the following experiment : 

Experiment. — To the dogs two and three I administered 
on the following day, as before, one and two grains of opium, 
respectively. As soon as the effects began to be manifested 
upon the condition of the brain, I opened the trachea of each, 
and, inserting the nozzle of a bellows, began the process of 
artificial respiration. In both dogs the congestion of the 
blood-vessels of the brain disappeared. The brain became 
collapsed, and the animals fell into a sound sleep, from which 
they were easily awakened. If the action of the bellows was 
stopped, and the animals were left to their own respiratory 
efforts, no change ensued in number two, but in number three 
the surface of the brain became dark, and stupor resulted. 

In order to be perfectly assured upon the subject, I pro- 
ceeded as follows with another dog : 

Experiment. — The animal was trephined as was the others, 
and five grains of opium given. At the same time the trachea 
was opened and the process of artificial respiration instituted. 
The brain became slightly congested, then collapsed, and sleep 
ensued. The sleep was sound, but the animal was easily awak- 
ened by tickling its ear. After I had continued the process 
for an hour and a quarter, I removed the nozzle of the bellows, 
and allowed the animal to breathe for itself. Immediately 



158 SLEEP. 

the vessels of the brain were filled with black blood, and the 
surface of the brain assumed a very dark appearance. 

The dog could no longer be aroused, and died one hour 
and a quarter after the process was stopped. 

I have only stated those points of the experiments cited 
which bear upon the subject under consideration, reserving 
for another occasion others of great interest. It is, however, 
shown that a small dose of opium excites the mind, because it 
increases the amount of blood in the brain ; that a moderate 
dose causes sleep, because it lessens the amount of blood ; and 
that a large dose produces stupor by impeding the respiratory 
process, and hence allowing blood loaded with carbon, and 
therefore poisonous, to circulate through the brain. 

It is also shown that the condition of the brain during stu- 
por is very different from that which exists during sleep. In 
the one case its vessels are loaded with dark blood; in the 
other they are comparatively empty, and the blood remains 
florid. 

Lately Ecker x has confirmed the results of these experi- 
ments by repeating them upon dogs and horses. 

I think it will be sufficiently established, in the course of 
these remarks, that sleep is directly caused by the circulation 
of a less quantity of blood through the cerebral tissues than 
traverses them while we are awake. This is the immediate 
cause of healthy sleep. Its exciting cause is, as we have 
seen, the necessity for repair. The condition of the brain 
which is favorable to sleep may also be induced by various 
other causes, such as heat, cold, narcotics, anaesthetics, intox- 
icating liquors, loss of blood, etc. If these agents are al- 
lowed to act excessively, or others, such as carbonic oxide, 
and all those which interfere with the oxygenation of the 
blood, are permitted to exert their influence, stupor results. 

The theory above enunciated, although proposed in a modi- 
fied form by Blumenbach several years since, and subsequent- 
ly supported by facts brought forward by other observers, has 
not been received with favor by any considerable number of 
physiologists. Before, therefore, detailing my own experi- 
ence, I propose to adduce a few of the most striking proofs of 
its correctness which I have been able to collect, together with 
the opinions of some of those inquirers who have recently 
studied the subject from this point of view. 

1 Cited by Marvaud in "Le sommeil et l'insomnie," Paris, 1881, p. 112. 



THE CAUSES OF SLEEP. 159 

Blumenbacli 1 details the case of a young man, eighteen 
years of age, who had fallen from an eminence and fractured 
the frontal bone, on the right side of the coronal suture. After 
recovery took place a hiatus remained, covered only by the 
integument. While the young man was awake this chasm 
was quite superficial, but as soon as sleep ensued it became 
very deep. The change was due to the fact that during sleep 
the brain was in a collapsed condition. From a careful ob- 
servation of this case, as well as from a consideration of the 
phenomena attendant on the hibernation of animals, Blumen- 
bacli 2 arrives at the conclusion that the proximate cause of 
sleep consists in a diminished flow of oxygenated blood to 
the brain. 

Playfair 3 thinks that sleep is due to "a diminished supply 
of oxygen to the brain." 

Dendy 4 states that there was, in 1821, at Montpellier, a 
woman who had lost part of her skull, and the brain and its 
^membranes lay bare. When she was in deep sleep the brain 
remained motionless beneath the crest of the cranial bones ; 
when she was dreaming it became somewhat elevated ; and 
when she was awake it was protruded through the fissure in 
the skull. 

Among the most striking proofs of the correctness of the 
view that sleep is due to diminished flow of blood to the head 
are the experiments of Dr. Alexander Fleming, 5 late Professor 
of Medicine, Queen's College, Cork. This observer states that, 
while preparing a lecture on the mode of operation of narcotic 
medicines, he conceived the idea of trying the effect of com- 
pressing the carotid arteries on the functions of the brain. 
The first experiment was performed on himself, by a friend, 
with the effect of causing immediate and deep sleep. The at- 
tempt was frequently made, both on himself and others, and 
always with success. " A soft humming in the ears is heard ; 
a sense of tingling steals over the body, and in a few seconds 
complete unconsciousness and insensibility supervene, and 
continue so long as the pressure is maintained." 

lu Elements of Physiology." Translated by John Elliotson, M. D. , etc., 
fourth edition, London, 1828, p. 191. 

2 Op. cit., p. 282, et seq. 

3 Northern Journal of Medicine, Iso. 1, 1844, p. 34. 

4 "The Philosophy of Mystery," London, 1841, p. 283. 

5 British and Foreign Medico- Chirurgical Review, Am. ed., April, 1S55, p. 404. 



160 SLEEP. 

Dr. Fleming adds that whatever practical value may be 
attached to his observations, they are at least important as 
physiological facts, and as throwing light on the causes of 
sleep. 

Quite recently the subject has been taken up by Dr. J. 
Leonard Corning, 1 who, in an interesting little book, considers 
the subject in all its details. Among other cases showing the 
influence of carotid compression in inducing sleep, is the case 
he adduces of a man who was suffering from a protracted and 
most violent attack of acute mania. The instrument devised 
by Dr. Corning was applied to the arteries, and, after the lapse 
of a few moments, his cries and struggles ceased, his eyelids 
drooped, and he began to oscillate to and fro in his chair. In 
this condition he suffered himself to be led to his bed ; there 
he remained quietly upon his back, evincing all the symptoms 
of drowsiness. In a shorter time than it takes to relate it he 
was wrapt in slumber. This repose had all the characteristics 
of physiological sleep. 2 

Dr. Bedford Brown, 3 of Alexandria, "Virginia, has recorded 
an interesting case of extensive compound fracture of the cra- 
nium, in which the opportunity was afforded him of examining 
the condition of the cerebral circulation while the patient was 
under the influence of an anaesthetic, preparatory to the opera- 
tion of trephining being performed. A mixture of ether and 
chloroform was used. Dr. Brown says : 

"Whenever the anaesthetic influence began to subside, 
the surface of the brain presented a florid and injected ap- 
pearance. The haemorrhage increased, and the force of the 
pulsation became much greater. At these times so great was 
the alternate heaving and bulging of the brain that we were 
compelled to suspend operations until they were quieted by a 
repetition of the remedy. Then the pulsations would dimin- 
ish, the cerebral surface recede within the opening of the 
skull, as if by collapse ; the appearance of the organ becom- 
ing pale and shrunken with a cessation of the bleeding. In 
fact, we were convinced that diminished vascularity of the 
brain was an invariable result of the impression of chloroform 
or ether. The changes above alluded to recurred sufficiently 
often, during the progress of the operation, in connection 



1 " Carotid Compression and Brain Rest," New York, 1882. 

a Op. cit., p. 24. 

3 American Journal of the Medical Sciences, October, 18G0, p. 399. 



THE CAUSES OF SLEEP. 161 

with the anaesthetic treatment, to satisfy ns that there could 
be no mistake as to the cause and effect." 

It will be shown, in the course of the present memoir, that 
Dr. Brown' s conclusions, though in the main correct, are erro- 
neous so far as they relate to the effect of chloroform upon 
the cerebral circulation ; nor does it appear that he employed 
this agent unmixed with ether in the case which he has re- 
corded so well. He has, probably, based his remarks on this 
point upon the phenomena observed when the compound of 
ether and chloroform was used, the action of pure chloro- 
form, as regards its effect upon the quantity of blood circu- 
lating through the brain, being the reverse of that which he 
claims for it. 

But the most philosophical and most carefully digested 
memoir upon the proximate cause of sleep which has yet 
been published is that of Mr. Durham. 1 Although my own 
experiments in the same direction, and which will be here- 
after detailed, were of prior date, I cheerfully yield all the 
honor which may attach to the determination of the question 
under consideration to this gentleman, who has not only 
worked it out independently, but has anticipated me several 
years in the publication, besides carrying his researches to a 
much further point than my own extended. 

With the view of ascertaining by ocular examination the 
vascular condition of the brain during sleep, Durham placed 
a dog under the influence of chloroform, and removed with a 
trephine a portion of bone as large as a shilling from the pari- 
etal region ; the dura mater was also cut away. During the 
continuance of the anaesthetic influence, the large veins of the 
surface of the pia mater were distended, and the smaller ves- 
sels were full of dark-colored blood. The longer the adminis- 
tration of the chloroform was continued, the greater was the 
congestion. As the effects of this agent passed off, the animal 
sank into a natural sleep, and then the condition of the brain 
was very materially changed. Its surface became pale, and 
sank down below the level of the bone ; the veins ceased to 
be distended, and many which had been full of dark blood 
could no longer be distinguished. When the animal was 
roused, the surface of the brain became suffused with a red 
blush, and it ascended into the opening through the skull. 

1 "The Physiology of Sleep." By Arthur E. Durham. "Guy's Hospital 
Reports," third series, vol. vi, 1860, p. 149. 
11 



162 SLEEP. 

As the mental excitement increased, the brain became more 
and more turgid with blood, and innumerable vessels sprang 
into sight. The circulation was also increased in rapidity. 
After being fed, the animal fell asleep, and the brain again 
became contracted and pale. In all these observations the 
contrast between the two conditions was exceedingly well 
marked. s 

To obviate any possible effects due to atmospheric press- 
ure, watch-glasses were applied to the opening in the skull, 
and securely cemented to the edges with Canada balsam. The 
phenomena observed did not differ from those previously no- 
ticed ; and, in fact, many repetitions of the experiment gave 
like results. 

Durham, in the next place, applied ligatures to the jugu- 
lar and vertebral veins, with the effect — as was to be expected 
— of producing intense congestion of the brain, attended with 
coma. This last condition he very properly separates from 
sleep, which is never caused by pressure from the veins. He 
likens sleep to the state induced by preventing the access of 
blood to the brain through the carotids, but does not allude 
to Fleming's researches on this point. 

From his observations, Durham deduces the following con- 
clusions : 

"1. Pressure of distended veins upon the brain is not the 
cause of sleep, for during sleep the veins are not distended ; 
and, when they are, symptoms and appearances arise which 
differ from those which characterize sleep. 

" 2. During sleep the brain is in a comparatively bloodless 
condition, and the blood in the encephalic vessels is not only 
diminished in quantity, but moves with diminished rapidity. 

"3. The condition of the cerebral circulation during sleep 
is, from physical causes, that which is most favorable to the 
nutrition of the brain tissue ; and, on the other hand, the 
condition which prevails during waking is associated with 
mental activity, because it is that which is most favorable to 
oxidation of the brain substance, and to various changes m 
its chemical constitution. 

"4. The blood which is derived from the brain during 
sleep is distributed to the alimentary and excretory organs, 

"5. Whatever increases the activity of the cerebral circu- 
lation tends to preserve wakefulness ; and whatever decreases 
the activity of the cerebral circulation, and, at the same time, 



THE CAUSES OF SLEEP. 163 

is not inconsistent with the general health of the body, tends 
to induce and favor sleep. Such circumstances may act pri- 
marily through the nervous or through the vascular system. 
Among those which act through the nervous system may be 
instanced the presence or absence of impressions upon the 
senses, and the presence or absence of exciting ideas. Among 
those which act through the vascular system may be men- 
tioned unnaturally or naturally increased or decreased force 
or frequency of the heart' s action. 

"6. A probable explanation of the reason why quiescence 
of the brain normally follows its activity is suggested by the 
recognized analogical fact that the products of chemical action 
interfere with the continuance of the action by which they 
are produced." ' 

Luys, 2 after stating the two opposite views relative to the 
state of the cerebral circulation during sleep, gives his adhe- 
sion on principles of analogy to that which holds to a dimin- 
ished afflux of blood. Taking the condition of the salivary 
glands during their periods of inaction as the basis of his 
argument, he says : 

" We are then naturally led, in making the application of 
known facts to those which are yet unknown, to say that the 
nervous tissue and the glandular tissue present, between 
themselves, the closest analogy, so far as circulatory phenom- 
ena and the double alternation of their periods of activity 
and repose are concerned. And that if the period during 
which the gland reconstitutes its immediate principles corre- 
sponds to a period of reduced activity of circulatory phenom- 
ena — to a state of relative anaemia — and that when it func- 
tionates it is awakened to a state in which its capillaries are 
turgid with blood, it is very admissible that the same circu- 
latory conditions should be present in the nervous tissue, and 
that the period of inactivity, or of sleep, should be character- 
ized by an anemic state. Inversely, the period of activity or 
wakefulness should be marked by an acceleration of the flow 

1 As I have recently been accused of doing injustice to Mr. Durham by re- 
fusing him the credit belonging to his investigations, it seems proper to state 
that the foregoing account of his researches is verbatim that given by me in a 
memoir entitled "Sleep and Insomnia," and published in the New York Medi- 
cal Journal for May, 1865, and subsequently in " Sleep and its Derangements," 
Philadelphia, 1869. 

2 " Recherches sur la systeme nerveux cerebro-spinal, sa structure, ses fonc- 
tions et ses maladies," Paris, 1865, p. 448. 



1G4: SLEEP. 

of blood, and by a kind of erethism of the vascular ele- 
ment." 

Having thus, in as succinct a manner as possible, brought 
forward the principal observations relative to the immediate 
cause of sleep, which up to the present time have been pub- 
lished, I come, in the next place, to detail the result of my 
own researches. 

In 1854 a man came under my observation who had, 
through a frightful railroad accident, lost about eighteen 
square inches of his skull. There was thus a fissure of his 
cranium three inches wide and six inches long. The lost por- 
tion consisted of a great part of the left parietal, and part of 
the frontal, occipital, and right parietal bones. The man, 
who was employed as a wood chopper, was subject to severe 
and frequent epileptic fits, during which I often attended 
him. In the course of my treatment I soon became ac- 
quainted with the fact that, at the beginning of the comatose 
condition which succeeded the fits, there was invariably an 
elevation of that portion of the scalp covering the deficiency 
in the cranium. As the stupor passed away, and sleep from 
which he could easily be aroused ensued, the scalp gradually 
became depressed. When the man was awake, the region of 
scalp in question was always nearly on a level with the upper 
surface of the cranial bones. I also noticed on several occa- 
sions that during natural sleep the fissure was deeper, and 
that in the instant of awaking the scalp covering it rose to a 
much higher level. 

After my attention was thus drawn to this subject, I ob- 
served that in young infants the portion of scalp covering the 
anterior fontanelle was always depressed during sleep and 
elevated during wakefulness. 

During the summer of 1860 I undertook a series of experi- 
ments, with the view of ascertaining the condition of the cere- 
bral circulation during sleep, of which the following is a brief 
abstract : 

A medium-sized dog was trephined over the left parietal 
bone, close to the sagittal suture, having previously been 
placed under the full anaesthetic influence of ether. The 
opening made by the trephine was enlarged with a pair of 
strong bone-forceps, so as to expose the dura mater to the ex- 
tent of a full square inch. This membrane was then cut away 
and the brain brought into view. It was sunk below the inner 



THE CAUSES OF SLEEP. 165 

surface of the skull, and but few vessels were visible. Those 
which could be perceived, however, evidently conveyed dark 
blood, and the whole exposed surface of the brain was of a 
purple color. As the anaesthetic influence passed off, the cir- 
culation of the blood in the brain became more active. The 
purple hue faded away, and numerous small vessels filled 
with red blood became visible ; at the same time the volume 
of the brain increased, and, when the animal became fully 
aroused, the organ protruded through the opening in the skull 
to such an extent that, at the most prominent part, its surface 
was more than a quarter of an inch above the external sur- 
face of the cranium. While the dog continued awake, the 
condition and position of the brain remained unchanged. 
After the lapse of half an hour sleep ensued. While this 
state was coming on I watched the brain very attentively. 
Its volume slowly decreased ; many of its smaller blood-ves- 
sels became invisible, and finally it was so much contracted 
that its surface, pale and apparently deprived of blood, was 
far below the level of the cranial wall. 

Two hours subsequently the animal was again etherized, in 
order that the influence of the ether upon the cerebral circula- 
tion might be observed from the commencement. At the time 
the dog was awake, and had a few minutes previously eaten a 
little meat and drank a small quantity of water. The brain 
protruded through the opening in the skull, and its surface 
was of a pink hue, with numerous red vessels ramifying over 
it. The ether was administered by applying to the muzzle 
of the animal a towel folded into the shape of a funnel, and 
containing a small sponge saturated with the agent. 

As soon as the dog began to inspire the ether, the appear- 
ance of the brain underwent a change of color, and its volume 
became less. As the process of etherization was continued, 
the color of the surface darkened to a deep purple, and it 
ceased to protrude through the opening. Finally, when a 
state of complete anaesthesia was reached, it was perceived 
that the surface of the brain was far below the level of the 
cranial fissure, and that its vessels conveyed black blood 
alone. 

Gradually the animal regained its consciousness ; the ves- 
sels resumed their red color, and the brain was again elevated 
to its former position. In this last experiment there did not 
appear to be any congestion of the brain. Had this condition 



166 SLEEP. 

existed, it would have been difficult to account for the dimi- 
nution in bulk, which certainly took place. There was evi- 
dently less blood in the cerebral tissue than there had been 
previously at the etherization ; but this blood, instead of 
being oxygenated, was loaded with excrementitial matters, 
and, consequently, was not fitted to maintain the brain in a 
condition of activity. 

The following morning, the dog being quite lively, I re- 
moved the sutures which had been placed in the skin, cover- 
ing the hole in the cranium, with the view of ascertaining the 
effects of chloroform upon the brain when introduced into 
the system by inhalation. Suppuration had not yet taken 
place, and the parts were in good condition. The opening in 
the skull was completely filled by the brain, and the surface 
of the latter was traversed by a great many small vessels car- 
rying red blood. The chloroform was administered in the 
same way in which the ether had been given the previous 
day. 

In a few seconds the change in color of the blood circulat- 
ing in the vessels began to take place, but there was no sink- 
ing of the brain below the level of the chasm in the skull. On 
the contrary, its protrusion was greater than before the com- 
mencement of the experiment. There was thus not only un- 
oxygenated blood circulating to too great an extent through 
the brain, but there was very decided congestion. 

The foregoing experiments were frequently repeated on 
other dogs, and also on rabbits, with like results. Within a 
short period I have in part gone over the ground again, with- 
out observing any essential point of difference in the effects 
produced. 

But, by means of an instrument designed in somewhat dif- 
ferent form by Dr. Weir Mitchell and myself, independently 
of each other, and which I described in 1869, x the state of the 
brain as regards its blood contents can be accurately deter- 
mined by ascertaining the degree of pressure exerted upon 
the fluid contained in the tube of the apparatus. The action 
is that of any other manometer. Many experiments per- 
formed with this instrument shows conclusively that sleep is 
produced by the blood supply of the brain suffering diminu- 
tion, and not, as some have supposed, the diminution being 

1 Quarterly Journal of Psychological Medicine and Medical Jurisprudence, 
January, 1869, p. 47. 



THE CAUSES OF SLEEP. 167 

caused by the sleep. Invariably it happens that the fall of 
the fluid, indicating a lessened amount of blood, takes place 
before the superinduction of sleep. 

I have also performed Fleming's experiment on the human 
subject in several instances with Coming's instrument, and 
then sleep was instantaneously produced. As soon as the 
pressure was removed from the carotids, the individual gained 
his consciousness. On dogs and rabbits I have performed it 
frequently, and, though, if the pressure be continued for 
longer than one minute, convulsions generally ensue, a state 
of insensibility resembling natural sleep is always the first 
result. Several years ago I had, through the kindness of my 
friend, Dr. Van Buren, the opportunity of examining a case 
which afforded strong confirmation of the correctness of the 
preceding views. It was that of a lady in whom both com- 
mon carotids were tied for a cirsoid aneurism, involving a 
great portion of the right side of the scalp. One carotid was 
tied by the late Dr. J. Kearney Rogers, and the other by Dr. 
Yan Buren, seven years before I saw the patient, with the 
effect of arresting the progress of the disease. No peculiar 
symptoms were observed in consequence of these operations, 
except the supervention of persistent drowsiness, which was 
especially well marked after the last operation, and which 
even then was at times quite troublesome. 

It has been alleged by some writers that although it is true 
that the amount of blood in the brain is reduced during sleep, 
yet that it is a consequence, not a cause, of the condition. But 
the experiments performed upon the carotid arteries by Flem- 
ing, Corning, and myself, as well as the phenomena of the 
case just cited, invalidate this hypothesis. Moreover, the 
instinct which I have described also shows the contrary, for 
sleep does not ensue before the fluid begins to fall in the tube, 
but an appreciable time thereafter. 

A similar view of the immediate cause of sleep is that of 
Mr. Moore. 1 He regards it as being produced by the contrac- 
tion of the arteries, and the consequent diminution of the 
quantity of arterial blood circulating through the brain. 

Dr. Cappie, 3 however, is of the opinion that sleep is the 
result of a succession of conditions. First, there is a modified 
nutrition in the nervous texture ; last, a pressure over the sur- 

1 "On Going to Sleep." 

2 "The Causation of Sleep," a Physiological Essay, Edinburgh, 1872, p. 36. 



168 SLEEP. 

face of the brain, caused by an increase in the amount of blood 
in that part ; and, as a connecting link between the two, a 
weakened capillary circulation through the brain itself. All 
this is very ingeniously argued, but it is nevertheless pure 
hypothesis, and cannot be accepted as contradicting positive 
experiments. 

The theory that sleep is due to a diminished amount of 
blood in the brain is combated by Langlet, 1 mainly on the 
ground that in sleep the pupils are contracted as established 
by Miiller, while in cerebral anaemia they are dilated. But 
the fact is, that the contraction of the pupils observed during 
sleep and their dilatation during the existence of cerebral 
anaemia are circumstances not resulting from the condition of 
the brain as regards its blood supply, but due to influences act- 
ing on the sympathetic nerve. As Claude Bernard has shown, 
the fibres of the cervical sympathetic which go to the cerebral 
vessels do not come from the same part of the spinal cord as 
those that supply the iris. Vulpian, 2 while doubting the 
correctness of the theory in question, admits that the state of 
the pupil affords no argument against its truth, and cites the 
experiments of Dr. Hughlings Jackson to the effect that oph- 
thalmoscopic examination showed that during sleep the optic 
papilla was paler than during wakefulness, and that the ar- 
teries were smaller and the veins larger. 

We thus see that the immediate cause of sleep is a diminu- 
tion of the quantity of blood circulating in the vessels of the 
brain, and that the exciting cause of periodical and natural 
sleep is the necessity which exists that the loss of substance 
which the brain has undergone, during its state of greatest 
activity, should be restored. To use the simile of the steam- 
engine again, the fires are lowered and the operatives go to 
work to repair damages and put the machine in order for next 
day's work. 

Whatever other cause is capable of lessening the quantity 
of blood in the brain is also capable of inducing sleep. There 
is no exception to this law, and hence we are frequently able 
to produce this condition at will. Several of these factors 
have been already referred to, but it will be interesting to con- 
sider them all somewhat more at length. 

1 "Etude critique sur quelques points de la pbysiologie du sommeil," These 
de Paris, 1872. 

1 " Lecous sur l'appareil vaso-moteur," Paris, 1875, t. ii, p. 149. 



THE CAUSES OF SLEEP. 169 

Heat. — Most persons in onr climate, and in those of higher 
temperatures, have felt the influence of heat in causing drow- 
siness, and eventually sleep, if the action is powerful enough 
and sufficiently prolonged. It is not difficult to understand 
the mode by which heat acts in giving rise to sleep. During 
the prevalence of high temperatures the blood flows in in- 
creased proportion to the surface of the body and to the 
extremities, and, consequently, the quantity in the brain is 
diminished. Sleep accordingly results unless the irritation in- 
duced by the heat is so great as to excite the nervous system. 
Heat applied directly to the head exerts, of course, a directly 
contrary effect upon the cerebral circulation, as we see in sun- 
stroke. Here there are internal cerebral congestion, loss of 
consciousness, stupor, etc. 

That the effect of heat is to dilate the vessels of the part 
subjected to its influence can be ascertained by putting the 
arm or leg into hot water. The swelling of the blood-vessels 
is then very distinctly seen. It will be shown hereafter that 
one of the best means of causing sleep in morbid wakefulness 
is the warm bath. 

Cold. — A slight degree of cold excites wakefulness at first, 
but if the constitution be strong the effect is to predispose to 
sleep. This it does by reason of the determination of blood to 
the surface of the body which moderate cold induces in vigor- 
ous persons. The ruddy complexion and warmth of the hands 
and feet produced in such individuals under the action of this 
influence are well known. 

But if the cold be very intense, or the reduction of tempera- 
ture sudden, the system, even of the strongest persons, cannot 
maintain a resistance, and then a very different series of phe- 
nomena result. Stupor, not sleep, is the consequence. The 
blood-vessels of the surface of the body contract, and the blood 
accumulates in the internal organs, the brain among them. 
Many instances are on record showing the effect of extreme 
cold in producing stupor, and even death. One of the most 
remarkable of these is that related by CaxDtain Cook in regard 
to an excursion of Sir Joseph Banks, Dr. Solander, and nine 
others, over the hills of Terra del Fuego. Dr. Solander, know- 
ing from his experience in Northern Europe that the stupor 
produced by severe cold would terminate in death unless re- 
sisted, urged his companions to keep in motion when they be- 
gan to feel drowsy. "Whoever sits down will sleep," said he, 



170 SLEEP. 

" and whoever sleeps will rise no more." Yet he was the first 
to feel this irresistible desire for repose, and entreated his com- 
panions to allow him to lie down. He was roused from his 
stupor with great difficulty and carried to a fire, when he re- 
vived. Two black men of the party, whose organizations were 
not so robust as those of the whites, perished. Dr. Whiting ' 
relates the case of Dr. Edward Daniel Clark, the celebrated 
traveller, who on one occasion came very near losing his life by 
cold. He had performed divine service at a church near Cam- 
bridge, and was returning home on horseback, when he felt 
himself becoming very cold and sleepy. Knowing the danger 
of yielding to the influence which was creeping over him, he 
put his horse into a fast trot, hoping thereby to arouse him- 
self from the alarming torpor. This means proving unavail- 
ing, he got down and led his horse, walking as fast as he 
could. This, however, did not long succeed. The bridle 
dropped from his arm, his legs became weaker and weaker, 
and he was just sinking to the ground when a gentleman who 
knew him came up in a carriage and rescued him. 

I have often myself noticed this effect of cold in produc- 
ing numbness and drowsiness, and on one occasion was nearly 
overcome by it. I was crossing the mountain ridge between 
Cebolleta and Covero, in New Mexico, when the thermometer 
fell in about two hours from 52° to 22° Fahrenheit. So great 
was the effect upon me that if I had had much farther to go 
I should probably have succumbed. As it was, I reached a 
rancho in time to be relieved, though several minutes elapsed 
before I was able to speak. The sensations experienced were 
rather agreeable than otherwise. There was a great desire to 
rest and to yield to the languor which was present, and there 
was a feeling of recklessness which rendered me perfectly in- 
different to the consequences. I should have dismounted 
from my horse and given way to the longing for repose if I 
had been able to do so. I have several times experienced 
very similar effects from change of air. A few years since 
I was so drowsy at the sea-coast, whither I had gone from a 
hot city, that it was with difficulty I could keep awake, even 
when engaged in active physical exercise. 

Another potent cause of sleep, and one of which we gen- 
erally avail ourselves, is the diminution of the power of the 
attention. To bring this influence into action generally re- 
1 " Cyclopaedia of Practical Medicine," art. " Cold." 



THE CAUSES OF SLEEP. 171 

quires only the operation of the will under circumstances 
favorable to the object in view. Shutting the eyes so as to 
exclude light, getting beyond the sound of noises, refraining 
from the employment of the other senses, and avoiding thought 
of all kind, will generally, when there is no preventing cause, 
induce sleep. To think and to maintain ourselves in connec- 
tion with the outward world by means of our senses require 
that the circulation of blood in the brain shall be active. 
When we isolate ourselves from external things, and restrain 
our thoughts, we lessen the amount of blood in the brain, and 
sleep results. It is not, however, always easy for us to do 
this. The nervous system is excited, ideas follow each other 
in rapid succession, and we lie awake hour after hour vainly 
trying to forget that we exist. The more the will is brought 
to bear upon the subject the more rebellious is the brain, and 
the more it will not be forced by such means into a state 
of quietude. We must then either let it run riot till it is 
worn out by its extravagancies, or we must fatigue it by 
requiring it to perform labor which is disagreeable. Just as 
we might do with an individual of highly destructive propen- 
sities, who was going about pulling down his neighbors' 
houses. We might, if we were altogether unable to stop him, 
let him alone till he had become thoroughly wearied with his 
exertions, or we might divert him from his plan by guiding 
him to some tough piece of work which would exhaust his 
strength sooner than would his original labor. 

Many ways of thus tiring the brain have been proposed. 
The more irksome they are, the more likely they are to prove 
effectual. Counting a hundred backward many times, listen- 
ing to monotonous sounds, thinking of some extremely dis- 
agreeable and tiresome subject, with many other devices, have 
been suggested, and have proved more or less effectual. Boer- 
haave ' states that he procured sleep by placing a brass pan in 
such a position that the patient heard the sound of water 
which was made to fall into it, drop by drop. In general 
terms, monotony predisposes to sleep. Dr. Dickson 8 quotes 
Southey's experience as related in "The Doctor," 3 and I also 
cannot do better than lay it before the reader, particularly 
as it indicates several methods which may be more effica- 

1 " Cyclopaedia of Anatomy and Physiology," vol. iv., pt. i, p. 681, art." Sleep. 1 ' 
8 "Essays on Life, Sleep, and Pain," Philadelphia, 1852, p. 87. 



8 (l 



The Doctor," etc., edited by Kev. John Wood Warter, London. 



172 SLEEP. 

cious with others than the one he found to succeed so admir- 
ably. 

" I put my arms out of bed ; I turned the pillow for the 
sake of applying a cold surface to my cheek ; I stretched my 
feet into the cold corner ; I listened to the river and to the 
ticking of my watch ; I thought of all sleepy sounds and of 
all soporific things — the flow of water, the humming of bees, 
the motion of a boat, the waving of a field of corn, the nodding 
of a mandarin's head on the chimney-piece, a horse in a mill, 
the opera, Mr. Humdrum's conversations, Mr. Proser's poems, 
Mr. Laxative's speeches, Mr. Lengthy's sermons. I tried the 
device of my own childhood, and fancied that the bed rushed 
with me round and round. At length Morpheus reminded me 
of Dr. Torpedo's Divinity Lectures, where the voice, the man- 
ner, the matter, even the very atmosphere and the streamy 
candle-light, were all alike somnific ; when he who, by strong 
effort, lifted up his head and forced open the reluctant eyes 
never failed to see all around him asleep. Lettuces, cowslip 
wine, poppy syrup, mandragora, hop pillows, spider's web 
pills, and the whole tribe of narcotics, up to bang and the 
black-drop, would have failed-^-but this was irresistible ; and 
thus, twenty years after date, I found benefit from having 
attended the course." 

Frequently the power of the attention is diminished by 
natural causes. After the mind has been strained a long time 
in one particular direction, and during which period the brain 
was doubtless replete with blood, the tension is at last re- 
moved, the blood flows out of the brain, the face becomes pale, 
and sleep ensues. It is thus, as Macnish 1 says, that "the 
finished gratification of all ardent desires has the effect of 
inducing slumber ; hence, after any keen excitement, the mind 
becomes exhausted and speedily relapses into this state." 

A gentleman, recently under my care for a paralytic affec- 
tion, informed me that he could at any time render himself 
sleepy by looking for a few minutes at a bright light, so as to 
fatigue the eyes, or by paying particular attention to the 
noises in the street, so as to weary the sense of hearing. It is 
well known that sleep may be induced by gentle frictions of 
various parts of the body, and doubtless the other senses are 
capable of being so exhausted, if I may use the expression, as 
to diminish the power of the attention, and thus lessen the 

1 Op. cit, p. 5. 



THE CAUSES OF SLEEP. 173 

demand for blood in the brain. As a consequence, sleep 
ensues. 

The cutting off of sensorial impressions aids in lessening 
the power of the attention, and thus predisposes to sleep. 
Stillness, darkness, the absence of any decided impression 
on the skin, and the non-existence of odors and flavors, ac- 
complish this end. In these respects, however, habit exer- 
cises great influence, and thus individuals, for instance, who 
are accustomed to continual loud noises, cannot sleep when 
the sound is interrupted. As we have already seen, however, 
the predisposition to sleep is, in healthy persons, generally so 
great that, when it has been long resisted, no sensation, how- 
ever strong it may be, can withstand its power. 

Digestion leads to sleep by drawing upon the brain for a 
portion of its blood. It is for this reason that we feel sleepy 
after the ingestion of a hearty dinner. A lady of my ac- 
quaintance is obliged to sleep a little after each meal. The 
clesire to do so is irresistible ; her face becomes pale, her ex- 
tremities cold, and she sinks into a quiet slumber, which 
lasts fifteen or twenty minutes. In this lady the amount of 
blood is not sufficient for the due performance of all the oper- 
ations of the economy. The digestive organs imperatively 
require an increased quantity, and the flow takes place from 
the brain, it being the organ with her which can best spare 
this fluid. As a rule, persons who eat largely, and have good 
digestive powers, sleep a great deal, and many persons are 
unable to sleep at night till they have eaten a substantial 
supper. The lower animals generally sleep after feeding, 
especially if the meal has been large. 

Excessive loss of blood produces sleep. We can very 
readily understand why this should be so, if we adopt the 
theory which has been supported in the foregoing pages. It 
would be exceedingly difficult to explain the fact upon any 
other hypothesis. I have seen many instances of somnolency 
due to this cause. It acts not only by directly lessening the 
quantity of blood in the brain, but also by so enfeebling the 
heart's action as to prevent a due supply of blood being sent 
to the cerebral vessels. 

Debility is almost always accompanied by a disposition to 
inordinate sleep. The brain is one of the first organs to feel 
the effects of a diminished amount of blood or of a depraved 
quality of this fluid being supplied ; and hence in old age, 



174 SLEEP. 

or under the influence of a deficient quantity of nutritious 
food, or through the action of some exhausting disease, there 
is generally more sleep than when the physical health is not 
deteriorated. 

The action of certain medicines, and of other measures 
capable of causing sleep, not coming within the range of 
ordinary application, will be more appropriately considered 
hereafter. 



CHAPTER II. 

THE NECESSITY FOB SLEEP. 

The state of general repose which accompanies sleep is of 
especial value to the organism in allowing the nutrition of the 
nervous tissue to go on at a greater rate than its destructive 
metamorphosis. The same effect is, of course, produced upon 
the other structures of the body ; but this is not of so much 
importance as regards them, for while we are awake they 
all obtain a not inconsiderable amount of rest. Even those 
actions which are most continuous, such as respiration and the 
pulsation of the heart, have distinct periods of suspension. 
Thus, after the contraction and dilatation of the auricles and 
ventricles of the heart, there is an interval during which the 
organ is at rest. This amounts to one fourth of the time 
requisite to make one pulsation and begin another. During 
six hours of the twenty-four the heart is therefore in a state 
of complete repose. If we divide the respiratory act into three 
equal parts, one will be occupied in inspiration, one in expira- 
tion, and the other by a period of quiescence. During eight 
hours of the day, therefore, the muscles of respiration and the 
lungs are inactive. And so with the several glands. Each 
has its time for rest. And, of the voluntary muscles, none, 
even during our most untiring waking moments, are kept in 
continued action. 

But for the brain there is no rest except during sleep, and 
even this condition is, in many instances, as we all know, only 
one of comparative quietude. So long as an individual is 
awake, there is not a single second of his life during which 
the brain is altogether inactive ; and, even while he is deprived 



THE NECESSITY FOR SLEEP. 175 

by sleep of the power of volition, nearly every other faculty 
of the mind is capable of being exercised ; and several of them, 
as the imagination and memory, for instance, are sometimes 
carried to a pitch of exaltation not ordinarily reached by 
direct and voluntary efforts. If it were not for the fact that 
all parts of the brain are not in action at the same time, and 
that thus some slight measure of repose is afforded, it would 
probably be impossible for the organ to maintain itself in a 
state of integrity. 

During wakefulness, therefore, the brain is constantly in 
action, though this action may be of such a character as not 
always to make us conscious of its performance. A great deal 
of the power of the brain is expended in the continuance of 
functional operations necessary to our well-being. During 
sleep these are altogether arrested, or else very materially re- 
tarded in force and frequency. 

Many instances of what Dr. Carpenter very happily calls 
" unconscious cerebration" will suggest themselves to the 
reader. We frequently find suggestions occurring to us sud- 
denly — suggestions which could only have arisen as the result 
of a train of ideas passing through our minds, but of which 
we have been unconscious. This function of the brain contin- 
ues in sleep, but not with so much force as during wakeful- 
ness. The movements of the heart, of the inspiratory mus- 
cles, and of other organs which perform either dynamic or 
secretory functions, are all rendered less active by sleep ; and 
during this condition the nervous system generally, obtains 
the repose which its ceaseless activity during our periods of 
wakefulness so imperatively demands. Sleep is thus neces- 
sary in order that the body, and especially the brain and ner- 
vous system, may be renovated by the formation of new tissue 
to take the place of that which by use has lost its normal 
characteristics. 

From what has been said it will be seen that the brain is 
no exception to the law which prevails throughout the whole 
domain of organic nature — that use causes decay. Its sub- 
stance is consumed by every thought, by every action of the 
will, by every sound that is heard, by every object that is 
seen, by every substance that is touched, by every odor that 
is smelled, by every painful or pleasurable sensation ; and so 
each instant of our lives witnesses the decay of some portion 
of its mass and the formation of new material to take its place. 



176 SLEEP. 

The necessity for sleep is due to the fact that during our wak- 
ing moments the formation of the new substance does not go 
on so rapidly as the decay of the old. The state of compara- 
tive repose which attends upon this condition allows the bal- 
ance to be restored, and hence the feeling of freshness and 
rejuvenation we experience after a sound and healthy sleep. 
The more active the mind, the greater the necessity for sleep, 
just as with a steamship, the greater the number of revolutions 
its engine makes, the more imperative is the demand for fuel. 

The power with which this necessity can act is oftentimes 
very great, and not even the strongest exertion of the will is 
able to neutralize it. I have frequently seen soldiers sleep on 
horseback during night marches, and have often slept thus 
myself. Galen on one occasion walked over two hundred 
yards while in a sound sleep. He would probably have gone 
farther but for the fact of his striking his foot against a stone, 
and thus awaking. 

The Abbe Richard states that once, when coming from the 
country alone and on foot, sleep overtook him when he was 
more than half a league from town. He continued to walk, 
however, though soundly asleep, over an uneven and crooked 
road. ' 

Even when the most stirring events are being enacted, 
some of the participants may fall asleep. Sentinels on posts 
of great danger cannot always resist the influence. To punish 
a man with death, therefore, for yielding to an inexorable law 
of his being, is not the least of the barbarous customs which 
are still in force in civilized armies. During the battle of the 
Nile many of the boys engaged in handing ammunition fell 
asleep, notwithstanding the noise and confusion of the action 
and the fear of punishment. And it is said that on the retreat 
to Corunna whole battalions of infantry slept while in rapid 
march. Even the most acute bodily sufferings are not always 
sufficient to prevent sleep. I have seen individuals who had 
been exposed to great fatigue, and who had while enduring 
it met with accidents requiring surgical interference, sleep 
through the pain caused by the knife. Damiens, the lunatic 
who attempted the assassination of Louis XV of France, and 
who was sentenced to be torn to pieces by four horses, was 
for an hour and a half before his execution subjected to the 
most infamous tortures, with red-hot pincers, melted lead, 

1 " La theorie des soDges," Paris, 1766, p. 206. 



THE NECESSITY FOR SLEEP. 177 

burning sulphur, boiling oil, and other diabolical contrivances, 
yet he slept on the rack, and it was only by continually chang- 
ing the mode of torture, so as to give a new sensation, that he 
was kept awake. He complained, just before his death, that 
the deprivation of sleep was the greatest of all his torments, 
and he also declared that, had he been bled as he had request- 
ed, he would never have committed the crime for which he 
suffered. 

Dr. Forbes Winslow 1 quotes from the Louisville Semi- 
Monthly Medical News the following case : 

" A Chinese merchant had been convicted of murdering his 
wife, and was sentenced to die by being deprived of sleep. 
This painful mode of death was carried into effect under the 
following circumstances : The condemned was placed in prison 
under the care of three of the police guard, who relieved each 
other every alternate hour, and who prevented the prisoner 
falling asleep night or day. He thus lived nineteen days with- 
out enjoying any sleep. At the commencement of the eighth 
day his sufferings were so intense that he implored the au- 
thorities to grant him the blessed opportunity of being stran- 
gled, guillotined, burned to death, drowned, garroted, shot, 
quartered, blown up with gunpowder, or put to death in any 
conceivable way their humanity or ferocity could invent. 
This will give a slight idea of the horrors of death from want 
of sleep." 

In infants the necessity for sleep is much greater than in 
adults, and still more so than in old persons. In the former 
the formative processes are much more active than those con- 
cerned in disintegration. Hence the greater necessity for fre- 
quent periods of repose. In old persons, on the contrary, 
decay predominates over construction, there is a decreased 
activity of the brain, the nervous system, and of all other 
organs, and thus the demand for rest and recuperation is 
lessened. 

The necessity for sleep is not felt by all organic beings 
alike. The differences observed are more due to variations 
in habits, modes of life, and inherent organic dispositions, 
than to any inequality in the size of the brain, although the 
latter has been thought by some authors to be the cause. It 
has been assumed that the larger the brain the more sleep is 
required. Perhaps this is true as regards the individuals of 

1 " On Obscure Diseases of the Brain," etc., London, 1860, p. 604, note. 
12 



178 SLEEP. 

any one species of animals, but it is not the case when species 
are compared with each other. In man, for instance, persons 
with large heads, as a rule, have large, well-developed brains, 
and, consequently, more cerebral action than individuals with 
small brains. There is accordingly a greater waste of cerebral 
substance, and an increased necessity for repair. 

This is not, however, always the case, as some individuals, 
with small brains have been remarkable for great mental ac- 
tivity. 

All animals sleep, and even plants have their periods of 
comparative repose. As Lelut says : * 

" ]STo one is ignorant of the nocturnal repose of plants. I 
say repose and nothing else. I do not say diminution or sus- 
pension of their sensibility, for plants have no sensibility. I 
say diminution of their organic actions — a diminution which 
is evident and characteristic in all, more evident and more 
characteristic in some. . . . 

" Their interior or vital movements are lessened, the flow of 
the sap and of other fluids which penetrate and rise in them 
is retarded. Their more mobile parts — the leaves, the flow- 
ers — show by their falling, their occlusion, their inclination, 
that their organic actions are diminished, and that a kind of 
repose has been initiated, which takes the place of the lying 
down which, with animals, is the condition and the result of 
sleep." 



CHAPTER III. 

THE PHYSICAL PHENOMENA OF SLEEP. 

The approach of sleep is characterized by a languor which, 
when it can be yielded to, is agreeable, but which, when cir- 
cumstances prevent this, is far from being pleasant. Many 
persons are rendered irritable as soon as they become sleepy, 
and children are especially liable to manifest ill-temper under 
the uncomfortable feelings they experience when unable to 
indulge the inclination to sleep. It is somewhat difficult to 
analyze the various phenomena which go to make up the con- 
dition called sleepiness. The most prominent feelings are an 

1 " Physiologie de la pensee. Recherche critique des rapports du corps a 
l'esprit. 1 ' Deuxieme edition, Paris, 1862, t. ii, p. 440. 



THE PHYSICAL PHENOMENA OF SLEEP. 179 

impression of weight in the upper eyelids, and of a general 
relaxation of the mnscles of the body, but there is besides an 
internal sensation of supineness, enervation, and torpor, to 
describe which is by no means easy. This sluggishness is 
closely allied in character, if not altogether identical, with that 
experienced before an attack of fainting, and is doubtless due 
to a like cause — a deficient quantity of blood in the brain. 
Along with this languor there is a general obtuseness of all 
the senses, which increases the separation of the mind from 
the external world, already initiated by the eyelids interpos- 
ing a physical obstruction to the entrance of light. Even 
when the eyelids have been removed, or from disease cannot 
be closed, the sight, nevertheless, is the first of the special 
senses to be abolished. Some animals, as the hare, for exam- 
ple, do not shut the eyes when asleep ; but even in them the 
ability to see disappears before the action of the other senses 
is suspended. 

These latter are not altogether abolished during sleep ; 
their acuteness is simply lessened. Taste is the first to fade, 
and then the smell ; hearing follows, and touch yields last 
of all, and is most readily re-excited. To awake a sleeping 
person, impressions made upon the sense of touch are more 
effectual than attempts to arouse through any of the other 
senses ; the hearing comes next in order, smell next, then 
taste, and the sight is the last of all in capacity for excitation. 
• During sleep the respiration is slower, deeper, and usually 
more regular than during wakefulness. The vigor of the pro- 
cess is lessened, and therefore there is a diminution of the 
pulmonary exhalations. In all probability, also, the ciliated 
ei3ithelium which lines the air-passages functionates with re- 
duced activity. Owing to this circumstance, and to the gen- 
eral muscular torpor which prevails, mucus accumulates in the 
bronchial tubes and requires to be expectorated on awaking. 

The circulation of the blood is rendered slower. The heart 
beats with more regularity, but with diminished force and 
frequency. As a consequence, the blood is not distributed to 
distant parts of the body so thoroughly and rapidly as during 
wakefulness, and accordingly the extremities readily lose their 
heat. Owing to the reduction in the activity of the respira- 
tory and circulatory functions, the temperature of the whole 
body falls, and coldness of the atmosphere is less easily re- 
sisted. 



180 SLEEP. 

The functions of the several organs concerned in diges- 
tion have their activity increased by sleep. The blood which 
leaves the brain goes, as Durham has shown, to the stomach 
and other abdominal viscera, and hence the quantities of the 
digestive juices are augmented, and the absorption of the nu- 
tritious elements of the food is promoted. . 

The urine is excreted in less quantity during sleep than 
when the individual is awake and engaged in mental or physi- 
cal employment, because the wear and tear of the system is 
at its minimum. 

The perspiration is likewise reduced in amount by sleep. 
In warm weather, however, the effort to go to sleep often causes 
an increase in the quantity of this excretion, just as would 
any other mental or bodily exertion. This circumstance has 
led some writers to a conclusion the reverse of that just ex- 
pressed. Others, again, have accepted the doctrine of Sanc- 
torius on this point without stopping to inquire into its 
correctness. This author, 1 among other aphorisms relating to 
sleep, gives the following : 

" Undisturbed sleep is so great a promoter of perspiration 
that, in the space of seven hours, fifty ounces of the concocted 
perspirable matter do commonly exhale out of strong bodies. 

' ' A man sleeping the space of seven hours is wont, insensi- 
bly, healthfully, and without any violence, to perspire twice 
as much as one awake." 

The observations of Sanctorius with his weighing chair 
led to a good many important results, but they were inexact 
so far as the function of the skin was concerned, in that they 
made no division between the loss by this channel and that 
which takes place through the lungs, for by perspiration in 
the above quotations he means not only the exhalation from 
the skin, but the products of respiration — aqueous vapor, 
carbonic acid, etc. His apparatus was, besides, very imper- 
fect, and could not possibly have given the delicate indications 
which the subject requires. 

Whether the condition of sleep promotes the absorption of 
morbid growths and accumulations of fluids is very doubtful. 
Macnish 9 contends that it does, but a priori reasoning would 
rather lead us to an opposite conclusion. Deficiencies are 
probably more rapidly made up during sleep than during 

1 " Medicina Statica ; or, Rules of Health," etc., London, 1676, p. 106, et seq. 
8 Op. cit., p. 6. 



THE PHYSICAL PHENOMENA OF SLEEP. 181 

wakefulness, and thus ulcers heal with more rapidity, owing 
to the increased formation of granulations which takes place ; 
but the removal of tumors, etc., by natural process involves 
the operation of forces the very opposite of those concerned 
in reparation, and observation teaches us that sleep is a con- 
dition peculiarly favorable to the deposition of the materials 
constituting morbid growths. Some writers have alleged that 
sleep accelerates the absorption of dropsical effusions, but the 
disappearance of such accumulations during the condition in 
question is clearly due to the mechanical causes depending 
upon the position of the body. 

It has also been asserted that there is an exaltation of the 
sexual feeling during sleep. It is difficult to arrive at any 
very definite conclusion on this point, but it is probable that 
here again the position of the body conjoined with the heat of 
the bed has much to do in producing the erotic manifestations 
occasionally witnessed. Every physician who has had much 
to do with cases of the kind knows that sleeping upon the 
back, by which means the blood gravitates to the generative 
organs and to the lower part of the spinal cord, will often give 
rise to seminal emissions with or without erotic dreams, and 
that such occurrences may generally be prevented by the in- 
dividual avoiding the dorsal decubitus and resting upon one 
side or the other while asleep. The erections which the gen- 
erality of healthy men experience in the morning before rising 
from bed are likewise due to the fact that the recumbent pos- 
ture favors the flow of blood to the penis and testicles. Such 
erections are usually unaccompanied by venereal desire. 

The ganglionic nervous system and the spinal cord continue 
in action during sleep, though generally with somewhat dimin- 
ished power and sensibility. The reflex faculty of the latter 
organ is still maintained, and thus various movements are 
executed without the consciousness of the brain being awak- 
ened. Somnambulism is clearly a condition of exaltation in 
the functions of the spinal cord without the controlling influ- 
ence of the cerebrum being brought into action. But, aside 
from this rather abnormal phenomenon, there are others which 
are entirely within the range of health, and which show that 
the spinal cord is awake, even though the sleep be most 
profound. Thus, for instance, if the position of the sleeper 
becomes irksome, it is changed ; if the feet become cold, they 
are drawn up to a warmer part of the bed ; and cases are 



1S2 SLEEP. 

recorded in which individuals have risen from bed and emp- 
tied a distended bladder without awaking. 

The instances brought forward in a previous chapter, of 
persons riding on horseback and walking during sleep, show 
the activity of the spinal cord, and not that the will is exer- 
cised ; and Cabanis ' is wrong in the view which he gives of 
such phenomena in the following extract. 

Speaking of cases like those just referred to, he says : 

' ' These rare instances are not the only ones in which move- 
ments are observed to be produced during sleep by that por- 
tion of the will which is awake ; for it is by virtue of certain 
direct sensations that a sleeping man moves his arm to brush 
away the flies from his face, that he draws the cover around 
him so as to envelop himself carefully, or that he turns in bed 
till he has found a comfortable position. It is the will which 
during sleep maintains the contraction of the sphincter of the 
bladder, notwithstanding the effort of the urine to escape." 

Such examples as the above we now know to be instances 
of reflex action, and as not, therefore, being due to the exer- 
cise of the will. 

Sleep favors the occurrence of certain pathological phe- 
nomena. Thus, individuals affected with haemorrhoids have 
the liability to haemorrhage increased when they are asleep. 
Several instances of the kind have come under my notice. In 
one the patient lost so large a quantity of blood that syncope 
ensued, and might have terminated fatally had not his con- 
dition been accidentally discovered. Bleeding from the lungs 
is also more apt to occur during sleep in those who are predis- 
posed to it. Darwin states that a man of about fifty years of 
age, subject to haemorrhoids, was also attacked with haemop- 
tysis three consecutive nights at about the same hour — two 
o'clock — being awakened thereby from a state of very pro- 
found sleep. He was advised to suffer himself to be roused 
at one o' clock, and to leave his bed at that hour. He did so 
with the result not only of entirely breaking up the haemor- 
rhagic disposition, but also of curing himself of very violent 
attacks of headache, to which he had been subject for many 
years. The contractile power of the sphincter of the bladder 
is often so weakened during sleep that enuresis is apt to occur, 
especially in children. 

Epileptic fits are also more liable to take place during sleep 

1 Op. city t. ii, p. 385. 



THE STATE OF THE MIND DUEING SLEEP. 183 

than at other times, a fact not always susceptible of easy ex- 
planation. In a case of epilepsy formerly under my charge, 
this proclivity is so well marked that the patient, a lady, 
scarcely ever goes to sleep without being attacked. Her face 
becomes exceedingly pale just before the fit, and, if then seen, 
the paroxysm can be entirely prevented by waking her. She 
is never attacked at other times, and I tried, with excellent 
results, the plan of making her sleep altogether during the day 
and of waking her as soon as her face became pallid. It is 
probable that the fits in her case were due to a diminished 
amount of blood in the brain, and this supposition is strength- 
ened by the additional fact that bromide of potassium — a 
substance which, as I have shown, lessens the amount of 
intracranial blood — invariably rendered her paroxysms more 
frequent and severe. 

Sleep predisposes to attacks of gout in those who have the 
gouty diathesis, and likewise favors exacerbations in several 
other diseases which it is scarcely necessary to allude to spe- 
cifically. The accession of fever toward night and the in- 
crease which takes place in pain due to inflammation are gen- 
erally associated with the approach of night, and have no direct 
relation with sleep. 

Certain other morbid phenomena, such as somnambulism 
and nightmare, which have a necessary relation with sleep, 
will be more appropriately considered in another place. 

On the other hand, sleep controls the manifestations of 
several diseases, especially those which are of a convulsive or 
spasmodic character. Thus, the paroxysms of chorea cease 
during sleep, as do likewise the spasms of tetanus and hy- 
drophobia. Headache is also generally relieved by sleep, 
though occasionally it is aggravated. 



CHAPTER IY. 

TEE STATE OF TEE MIND DURING SLEEP. 

We have seen that, though during sleep the operations of 
the senses are entirely suspended as regards the effects of 
ordinary impressions, the purely animal functions of the body 
continue in action. The heart beats, the lungs respire, the 



184 SLEEP. 

stomach, the intestines and their accessory organs digest, the 
skin exhales vapor, and the kidneys secrete nrine. With 
the central nervous system, however, the case is very differ- 
ent ; for, while some parts retain the property of receiving 
impressions or developing ideas, others have their actions di- 
minished, exalted, perverted, or altogether arrested. 

In the first place, there is, undoubtedly, during sleep, a 
general torpor of the sensorium, which prevents the appreci- 
ation of the ordinary excitations made upon the organs of 
the special senses. So far as the nerves themselves are con- 
cerned, there is no loss of their irritability or conducting 
power, and the impressions made upon them are, accordingly, 
perfectly well conveyed to the brain. The suspension of the 
operations of the senses is not, therefore, due to any loss of 
function in the optic nerve, the auditory nerve, the olfactory 
nerve, the gustatory nerve, or the cranial or spinal nerves 
concerned in the sense of touch, but solely to the inability of 
the brain to take cognizance of the impressions conveyed to it. 
In regard to the cause of this torpor, I have given my views 
in a previous chapter. 

Now, it must not be supposed that, because mild excitations 
transmitted by the nerves of the special senses are incapable 
of making themselves felt, that, therefore, the brain is in a 
state of complete repose throughout all its parts. So far from 
such a condition existing, there are very decided proofs that 
several faculties are exercised to a degree almost equalling 
that reached during wakefulness, and we know that, if the 
irritations made upon the senses be sufficiently strong, the 
brain does appreciate them, and the sleep is broken. This 
ability to be readily roused through the senses constitutes 
one of the main differences between sleep and stupor, upon 
which stress has been already laid. 

Relative to the different faculties of the mind as affected 
by sleep great variations are observed. It has been thought 
by some authors that several of them are really exalted 
above the standard attained during wakefulness, but this is 
probably a wrong view. The predominance which one or two 
mental qualities apparently assume is not due to any abso- 
lute exaggeration of power, but to the suspension of the action 
of other faculties, which, when we are not asleep, exercise a 
governing or modifying influence. Thus, for instance, as re- 
gards the imagination — the faculty of all others which appears 



THE STATE OF THE MIND DURING SLEEP. 185 

to be most increased — we find, when we carefully study its 
manifestations in our own persons, that although there is often 
great brilliancy in its vagaries, that uncontrolled as it is by 
the judgment, the pictures which it paints upon our minds 
are usually incongruous and silly in the extreme. Even 
though the train of ideas excited by this faculty when we are 
asleep be rational and coherent, we are fully conscious on 
awaking that we are capable of doing much better by inten- 
tionally setting the brain in action and governing it by our 
intellect and will. 

Owing to the fact that these two faculties of the mind are 
incapable of acting normally during sleep, the imagination 
is left absolutely without controlling influence. Indeed, we 
are often cognizant, in those dreams which take place when we 
are half awake, of an inability to direct it. The impressions 
which it makes upon the mind are therefore intense, but of 
very little durability. Many stories are told of its power — 
how problems have been worked out, poetry and music com- 
posed, and great undertakings planned ; but, if we could get 
at the truth, we should probably find that the imagination of 
sleep had very little to do with the operations mentioned. 
Indeed, it is doubtful if the mind of a sleeping person can 
originate ideas. Those which are formed are, as Locke ' re- 
marks, almost invariably made up of the waking man's ideas, 
and are for the most part very oddly put together ; and we 
are all aware how commonly our dreams are composed of ideas, 
or based upon events which have recently occurred to us. 

In the previous section to the one just quoted, Locke re- 
fers to the exaggeration of ideas which form so common a 
feature of our mental actions during sleep. "It is true," he 
says, ' ' we have sometimes instances of perception while we 
are asleep, and retain the memory of those thoughts ; but, 
how extravagant and incoherent for the most part they are, 
how little conformable to the perfection and order of a ra- 
tional being, those acquainted with dreams need not be told." 

And yet many remarkable stories are related which tend 
to show the high degree of activity possessed by the mind 
during sleep. Thus, it is said of Tartini, 2 a celebrated musi- 

1 " An Essay concerning Human Understanding," book ii, section 17. 

2 " Encyclopaedia Americana," Philadelphia, 1832, vol. xii, p. 143, art. " Tar- 
tini" ; "and "L'imagination consideree dans ses effets directs sur 1'homme et les 
animaux," etc. Par J. B. Demangeon. Seconde edition, Paris, 1829, p. 161. 



186 SLEEP. 

cian of the eighteenth century, that one night he dreamed he 
had made a compact with the devil, and bound him to his 
service. In order to ascertain the musical abilities of his ser- 
vitor, he gave him his violin, and commanded him to play a 
solo. The devil did so, and performed so admirably that 
Tartini awoke with the excitement produced, and, seizing his 
violin, endeavored to repeat the enchanting air. Although 
he was unable to do this with entire success, his efforts were 
so far effectual that he composed one of the most admired of 
his pieces, which, in recognition of its source, he called the 
"Devil's Sonata." 

Coleridge gives the following account of the composition 
of the fragment, Kublai Khan : 

"In the summer of 1797 the author, then in ill-health, 
had retired to a lonely farm-house, between Perlock and Lin- 
ton, on the Exmoor confines of Somerset and Devonshire. In 
consequence of a slight indisposition, an anodyne had been 
prescribed, from the effects of which he fell asleep in his chair 
at the moment that he was reading the following sentence, or 
words of the same substance, in 'Purchas's Pilgrimage' : ' Here 
the Khan Kublai commanded a palace to be built, and a stately 
garden thereunto. And thus ten miles of fertile ground were 
enclosed with a wall.' The author continued for about three 
hours in a profound sleep, at least of the external senses, dur- 
ing which time he had the most vivid confidence that he could 
have composed not less than from two to three hundred lines, 
if that, indeed, can be called composition, in which all the 
images rose up before him as things with a parallel produc- 
tion of the corresponding expression without any sensation or 
consciousness of effort. On awaking, he appeared to himself 
to have a distinct recollection of the whole ; and, taking his 
pen, ink, and paper, instantly and eagerly wrote down the 
lines that are here preserved. At this moment he was unfor- 
tunately called out by a person on business from Perlock, and 
detained by him above an hour ; and on his return to his 
room found, to his no small surprise and mortification, that 
though he still retained some vague and dim recollection of 
the general purport of the vision, yet, with the exception of 
some eight or ten scattered lines and images, all the rest had 
passed away like the images on the surface of a stream into 
which a stone had been cast, but, alas! without the 'after- 
restoration of the latter." 



THE STATE OF THE MIND DURING SLEEP. 187 

Dr. Cromwell, 1 citing the above instance of poetic inspira- 
tion during sleep, states that, having, like Coleridge, taken an 
anodyne during a painful illness, he composed the following 
lines of poetry, which he wrote down within half an hour after 
awaking. These lines, though displaying considerable imagi- 
nation, are not remarkable for any other quality. 

" Lines composed in sleep on the night of January 9, 

1857 : 

" Scene. — Windsor Forest. 

"At a vista's end stood the queen one day 
Kelieved by a sky of the softest hue ; 
It happen'd that a wood-mist, risen new, 
Had made that white which should have been blue. 
A sunbeam sought on her form to play ; 
It found a nook in the bowery nave, 
Through which with its golden stem to lave 
And kiss the leaves of the stately trees 
That fluttered and rustled beneath the breeze ; 
But it touched not her, to whom 'twas given 
To walk in a white light pure as heaven." 

In the last two of these instances it is impossible to say 
whether the individuals were really asleep or not, as the opium 
or other narcotic taken is a very disturbing factor in both con- 
ditions, and doubtless was the exciting cause of the activity 
in the imagination. No more graphic account of the effects of 
opium in arousing the imagination to its highest pitch has 
been written than that given by De Quincey. 2 He says : 

"At night when I lay awake in bed, vast processions 
passed along in mournful pomp ; friezes of never - ending 
stories, that to my feelings were as sad and solemn as if they 
were stories drawn from times before (Edipus or Priam, before 
Tyre, before Memphis. And at the same time a correspond- 
ing change took place in my dreams ; a theatre seemed sud- 
denly opened and lighted up within my brain, which presented 
nightly spectacles of more than earthly splendor." And then, 
after referring to the various scenes of architectural magnifi- 
cence, and of beautiful women which his imagination con- 
ceived, and which forcibly recalls to our minds the poetical 

1 The " Soul and the Future Life." Appendix viii. Quoted by Seafield in 
*' The Literature and Curiosities of Dreams," etc., London, 1865, vol. ii, p. 229. 
3 " Confessions of an English Opium-Eater," Boston, 1866, p. 109. 



1S8 SLEEP. 

effusions of Coleridge and Cromwell, lie gives the details of 
another dream, in which he heard music. ' ' A music of prepa- 
ration, of awakening suspense ; a music like the opening of 
the Coronation Anthem, and which like that gave the feeling 
of a vast march, of infinite cavalcades filing off, and the tread 
of innumerable armies." 

In reference to this subject, Dr. Forbes Winslow * relates 
the following interesting case : 

"A feeble, sensitive lady, suffering from a uterine affec- 
tion, writes to us as follows concerning the influence of three 
or four sixteenth-of -a-grain doses of hydrochlorate of morphia : 
* After taking a few doses of morphia, I felt a sensation of ex- 
treme quiet and wish for repose, and, on closing my eyes, vis- 
ions, if I may so call them, were constantly before me, and as 
constantly changing in their aspect: scenes from foreign lands, 
lovely landscapes, with tall, magnificent trees covered with 
drooping foliage, which was blown gently against me as I 
walked along. Then, in an instant, I was in a besieged city 
filled with armed men. I was carrying an infant, which was 
snatched from me by a soldier and killed upon the spot. A 
Turk was standing by with a cimeter in his hand, which I 
seized, and, attacking the man who had killed the child, I 
fought most furiously with him and killed him. Then I was 
surrounded, made prisoner, carried before a judge, and accused 
of the deed ; but I pleaded my own cause with such a burst 
of eloquence (which, by the by, I am quite incapable of in my 
right mind) that judge, jury, and hearers acquitted me at 
once. Again, I was in an Eastern city visiting an Oriental 
lady, who entertained me most charmingly. We sat together 
on rich ottomans, and were regaled with supper and confec- 
tionery. Then came soft sounds of music at a distance, while 
fountains were playing and birds singing, and dancing girls 
danced before us, every movement being accompanied with 
the tinkling of silver bells attached to their feet. But all this 
suddenly changed, and I was entertaining the Oriental lady 
in my own house, and, in order to please her delicate taste, I 
had everything prepared as nearly as possible after the fash- 
ion with which she had so enchanted me. She, however, to 
my no small surprise, asked for wine, and took not one, two, 
or three glasses, but drank freely, until at last I became ter- 
rified that she would have to be carried away intoxicated. 

1 Journal of Psychological Medicine and Mental Pathology, July, 1859, p. 44. 



THE STATE OF THE MEND DURING SLEEP. 189 

While considering what course I had better adopt, several 
English officers came in, and she at once asked them to drink 
with her, which so shocked my sense of propriety that the 
scene changed and I was in darkness. 

" l Then I felt that I was formed of granite, and immovable. 
Suddenly a change came again over me, and I found that I 
consisted of delicate and fragile basket-work. Then I became 
a danseuse, delighting an audience and myself by movements 
which seemed barely to touch the earth. Presently beautiful 
sights came before me, treasures from the depth of the sea, 
gems of the brightest hues, gorgeous shells, coral of the rich- 
est colors, sparkling with drops of water, and hung with lovely 
sea- weed. My eager glances could not take in half the beauti- 
ful objects that passed before me during the incessant changes 
the visions underwent. jSTow I was gazing upon antique 
brooches and rings from buried cities ; now upon a series of 
Egyptian vases ; now upon sculptured wood- work blackened 
by time ; and lastly I was buried amid forests of tall trees, 
such as I had read of but never seen. 

" ' The sights that pleased me most I had power to a cer- 
tain extent to prolong, and those that displeased me I could 
occasionally set aside, and I awoke myself to full conscious- 
ness once or twice while under the influence of the morphia 
by an angry exclamation that I would not have it. I did not 
once lose my personal identity.' 

" The lady almost invariably suffers more or less from hal- 
lucinations of the foregoing character if it becomes necessary 
to administer to her an opiate ; and, on analyzing her visions, 
she can generally refer the principal portions of them, not- 
withstanding their confusion and distortion, to works that she 
has recently read." 

Opium, in certain doses, increases the amount of blood in 
the brain, and this induces a condition very different from 
that of sleep. In this fact we have an explanation of the ac- 
tivity of the imagination as one of its prominent effects. That 
Coleridge should have composed the Kublai Khan under its 
influence is in no wise remarkable. It is probable, however, 
that the full influence of his mind was exerted upon it after 
he awoke to consciousness, and that the wild fancies excited 
by the opiate, and based upon what he had been previously 
reading, formed the substratum of his conceptions. In any 
event, the ideas contained in this fragment are no more fam 



190 SLEEP. 

ciful than those which occurred to De Quincey and the lady 
whose case has just been recorded. 

The imagination may therefore be active during sleep, but 
we have no authentic instance on record that it has, unaided 
by causes which exercise a powerful influence over the intra- 
cranial circulation, led to the production of- any ideas which 
could not be excelled by the individual when awake. Perhaps 
the most striking case in opposition to this opinion is one de- 
tailed by Abercrombie, 1 who says : 

" The following anecdote has been preserved in a family of 
rank in Scotland, the descendants of a distinguished lawyer 
of the last age. This eminent person had been consulted re- 
specting a case of great importance and much difficulty, and 
he had been studying it with intense anxiety and attention. 
After several days had been occupied in this manner, he was 
observed by his wife to rise from his bed in the night and go to 
a writing-desk which stood in the bedroom. He then sat down 
and wrote a long letter, which he put carefully by in the desk 
and returned to bed. The following morning. he told his wife 
that he had had a most interesting dream ; that he had dreamt 
of delivering a clear and luminous opinion respecting a case 
which had exceedingly perplexed him, and that he would 
give anything to recover the train of thought which had passed 
before him in his dream. She then directed him to the writ- 
ing-desk, where he found the opinion clearly and fully writ- 
ten out, and which was afterward found to be perfectly cor- 
rect." 

It is probable that this gentleman was actually awake 
when he arose from the bed and wrote the paper referred 
to, and that in the morning he mistook the circumstance 
for a dream. It is not at all uncommon for such errors to 
be committed, especially under the condition of mental anx- 
iety and fatigue. A gentleman informed me only a short 
time since that, going to bed after a very exciting day, he 
thought the next morning that he had dreamt of a fire oc- 
curring in the vicinity of his house. To his surprise his 
wife informed him that the supposed dream was a reality, 
and that he had got up to the window, looked at the fire, 
conversed with her concerning it, and that he was at the time 
fully awake. 

1 "Inquiries concerning the Intellectual Powers and the Investigation of 
Truth," tenth edition, London, 1840, p. 304. 



THE STATE OF THE MIND DUEING SLEEP. 191 

Brierre de Boismont * relates the following instance, which 
is to the same effect : 

"In a convent in Anvergne an apothecary was sleeping 
with several persons. Being attacked with nightmare, he 
charged his companions with throwing themselves on him 
and attempting to strangle him. They all denied the asser- 
tion, telling him that he had passed the night without sleep- 
ing, and in a state of high excitement. In order to convince 
him of this fact, they prevailed on him to sleep alone in a 
room carefully closed, having previously given him a good 
supper, and even made him partake of food of a flatulent nat- 
ure. The paroxysm returned ; but on this occasion he swore 
that it was the work of a demon, whose face and figure he 
perfectly described." 

That the imagination may in its flights during sleep strike 
upon fancies which are subsequently developed by the reason 
into lucid and valuable ideas, is very probable. It would 
be strange if, from among the innumerable absurdities and 
extravagances to which it attains, something fit to be appro- 
priated by the mind should not occasionally be evolved, and 
thus there are many instances mentioned of the starting- 
point of important mental operations having been taken dur- 
ing sleep. Some of these may be based upon fact, but the 
majority are probably of the class of those just specified, or oc- 
curred at an age of the world when a belief in the supernatu- 
ral exercised a greater power over men's minds than it does 
at the present day. Among the most striking of them are the 
following : 

Galen declares that he owed a great part of his knowledge 
to the revelations made to him in dreams. Whether this 
was really the case or not we can in a measure determine by 
recalling the fact that he was a believer in the prophetic 
nature of dreams, and states that a man having dreamt that 
one of his legs was turned into stone, soon afterward became 
paralytic in this limb, although there was no evidence of 
approaching disease. Galen also conducted his practice by 
dreams, for an athlete, having dreamt that he saw red spots, 
and that the blood was flowing out of his body, was supposed 
by Galen to require blood-letting, which operation was ac- 
cordingly performed. 

1 "A History of Dreams, Visions, Apparitions, 1 ' etc., Philadelphia, 1855, 
p. 184. 



192 SLEEP. 

It has been said ' that the idea of the " Divina Commedia" 
occurred to Dante during sleep. There is nothing at all im- 
probable in this supposition, though I have been unable to 
trace it to any definite source. 

Cabanis 2 states that Condillac assured him that often dur- 
ing the course of his studies he had to leaye them unfinished 
in order to sleep, and that on awaking he had more than once 
found the work upon which he was engaged brought to a con- 
clusion in his brain. 

These were clearly instances of " unconscious cerebration," 
of that power which the brain possesses to work out matters 
which have engaged its attention, without the consciousness 
of the individual being aroused to a knowledge of the labor 
being performed. It is not unlikely that this kind of mental 
activity goes on to some extent during sleep ; but, as it is of 
such a character that the mind does not take cognizance of 
its operations, I do see how the exact period of its perform- 
ance can be ascertained. 

Jerome Cardan believed that he composed books while 
asleep, and his case is often adduced as an example of the 
height to which the imagination can attain during sleep. 
But this great man was superstitious to an extreme degree ; 
he believed that he had a familiar spirit from whom he re- 
ceived intelligence, warnings, and ideas, and asserted that 
when awake he frequently saw long processions of men, 
women, animals, trees, castles, instruments of various kinds, 
and many figures different from anything in this world. His 
evidence relative to his compositions and mathematical labors 
when asleep is not therefore of a trustworthy character. 

As regards the memory in sleep, it is undoubtedly exer- 
cised to a considerable extent. In fact, whatever degree of 
activity the mind may then exhibit is based upon events the 
recollection of which has been retained. But there is more 
or less error mingled with a small amount of truth. The un- 
bridled imagination of the sleeper so distorts the simplest cir- 
cumstances as to render their recognition a matter of no small 
difficulty, and thus it scarcely if ever happens that events are 
reproduced during sleep exactly as they occurred, or as they 
would be recalled by the mind of the individual, when awake. 
Frequently, also, recent events which have made a strong im- 

1 ^Sracario, " Du sommeil, des r6ves et du somnambulisme," Paris, 1857, p. 59. 
* J Op. cit., t. ii, p. 395. 



THE STATE OF THE MIND DUEING SLEEP. 193 

pression on our minds are forgotten, as when we dream of 
seeing and conversing with persons not long dead. 

And yet it has sometimes happened that incidents or 
knowledge which had long been overlooked or forgotten, or 
which could not be remembered by any effort during wake- 
fulness, have been strongly depicted during sleep. Thus Lord 
Monboddo 1 states that the Countess de Laval, a woman of 
perfect veracity and good sense, when ill, spoke during sleep 
in a language which none of her attendants understood, and 
which even she was disposed to regard as gibberish. A nurse 
detected the dialect of Brittany ; her mistress had spent her 
childhood in that province, but had lost all recollection of the 
Breton tongue, and could not understand a word of what she 
said in her dreams. Her utterances applied, however, exclu- 
sively to the experience of childhood, and were infantile in 
structure. 

Abercrombie 2 relates the case of a gentleman who was very 
fond of the Greek language, and who, in his youth, had made 
considerable progress in it. Subsequently, being engaged in 
other pursuits, he so entirely forgot it that he could not even 
read the words ; often, however, in his dreams he read Greek 
works, which he had been accustomed to use at college, and 
had a most vivid impression of fully understanding them. 

Many other instances of the action of memory during sleep 
might be brought forward, but the subject will be more appro- 
priately considered in the chapter on dreams. 

The judgment is frequently exercised when we are asleep, 
but almost invariably in a perverted manner. In fact, we 
scarcely ever estimate the events or circumstances which 
appear to occur in our dreams at their real value, and very 
rarely from correct conceptions of right and wrong. High- 
minded and honorable men do not scruple during sleep to 
sanction the most atrocious acts, or to regard with compla- 
cence ideas which, in their waking moments, would fill them 
with horror. Delicate and refined women will coolly enter 
upon a career of crime, and the minds of hardened villains 
are filled with the most elevated and noble sentiments. The 
deeds which we imagine we perform in our sleep are generally 
inadequate to or in excess of what the apparent occasion re- 

1 " Ancient Metaphysics." Quoted in Dr. Forbes Winslow's Medical Critic 
and Psychological Journal, No. vi, April, 1862, p. 206. 
3 Op. cit., p. 283. 
13 



194: SLEEP. 

quires, and we lose so entirely the ideas of probability and 
possibility that no preposterous vision appears otherwise than 
as perfectly natural and correct. Thus, a physician dreamed 
that he had been transformed into a monolith, which stood 
grandly and alone in the vast desert of the Sahara, and had 
so stood for ages, while generation after generation wasted 
and melted away around him. Although unconscious of hav- 
ing organs of sense, this column of granite saw the mountains 
growing bald with age, the forests drooping with decay, and 
the moss and ivy creeping around its crumbling base. 1 

But, although in this instance there was some conception 
of time, as shown in the association of the evidences of decay 
with the lapse of years, there is in general no correct idea on 
this subject. Without going into details which more appro- 
priately belong to another division of this treatise, I quote the 
following remarkable example from the essay last cited. It 
appeared originally in a biographical sketch of Lavalette, pub- 
lished in the Bevue de Paris, and is related by Lavalette as 
occurring to him while in prison : 

" One night, while I was asleep, the clock of the Palais de 
Justice struck twelve and awoke me. I heard the gate open 
to relieve the sentry, but I fell asleep again immediately. In 
this sleep I dreamt that I was standing in the Rue St. Honore. 
A melancholy darkness spread around me ; all was still ; nev- 
ertheless, a slow and uncertain sound soon arose. All of a 
sudden I perceived at the bottom of the street, and advancing 
toward me, a troop of cavalry — the men and horses, however, 
all flayed. The men held torches in their hands, the red 
flames of which illuminated faces without skin, and bloody 
muscles. Their hollow eyes rolled fearfully in their sockets, 
their mouths opened from ear to ear, and helmets of hanging 
flesh covered their hideous heads. The horses dragged along 
their own skins in the kennels, which overflowed with blood 
on all sides. Pale and dishevelled women appeared and dis- 
appeared at the windows in dismal silence ; low, inarticulate 
groans filled the air, and I remained in the street alone pet- 
rified with horror, and deprived of strength sufficient to seek 
my safety in flight. This horrible troop continued passing 
along rapidly in a gallop, and casting frightful looks upon 
me. Their march continued, I thought, for five hours, and 

1 " Dream Thought and Dream Life." Medical Critic and Psychological Jour- 
nal," No. vi, April, 1862, p. 199. 



THE STATE OF THE MIND DURING SLEEP. 195 

they were followed by an immense number of artillery wagons 
full of bleeding corpses, whose limbs still quivered ; a disgust- 
ing smell of blood and bitumen almost choked me. At length 
the iron gates of the prison, shutting with great force, awoke 
me again. I made my repeater strike ; it was no more than 
midnight, so that the horrible phantasmagoria had lasted no 
more than two or three minutes — that is to say, the time neces- 
sary for relieving the sentry and shutting the gate. The cold 
was severe and the watchword short. The next day the turn- 
key confirmed my calculations. I, nevertheless, do not re- 
member one single event in my life the duration of which I 
have been able more exactly to calculate, of which the details 
are deeper engraven on my memory, and of which I preserve 
a more perfect consciousness." 

No instance can more strikingly exemplify aberration of 
the faculty of judgment than the above. There was no aston- 
ishment felt with the horror experienced, but all the impossi- 
ble events which appeared to be occurring were accepted as 
facts, which might have taken place in the regular order of 
nature. 

An important question connected with the exercise of judg- 
ment is : Does the dreamer know that he is dreaming ? Some 
authors assert that this knowledge is possible, others that it 
is not. The following account is interesting, and I therefore 
transcribe it, especially as it has not to my knowledge been 
heretofore published in this country. 

In a letter to the Rev. William Gregory, Dr. Thomas Reid * 
says : 

" About the age of fourteen I was almost every night un- 
happy in my sleep from frightful dreams. Sometimes hang- 
ing over a frightful precipice and just ready to drop down ; 
sometimes pursued for my life and stopped by a wall or by a 
sudden loss of all strength ; sometimes ready to be devoured 
by a wild beast. How long I was plagued by such dreams I 
do not now recollect. I believe it was for a year or two at 
least ; and I think they had quite left me before I was fifteen. 
In those days I was much given to what Mr. Addison in one 
of his ' Spectators ' calls castle-building, and, in my evening 
solitary walk, which was generally all the exercise I took, 

1 " Account of the Life and Writings of Thomas Reid, D. D.," p. cxliv, pre- 
fixed to " Essays on the Powers of the Human Mind." By Thomas Reid, D. D., 
etc., Edinburgh, 1803, vol. i. 



196 SLEEP. 

my thoughts would hurry me into some active scene, where I 
generally acquitted myself much to my own satisfaction, and 
in these scenes of imagination I performed many a gallant ex- 
ploit. At the same time, in my dreams, I found myself the 
most arrant coward that ever was. Not only my courage, but 
my strength failed me in every danger, and I often rose from 
my bed in the morning in such a panic that" it took some time 
to get the better of it. I wished very much to get free of 
these uneasy dreams, which not only made me unhappy in 
sleep, but often left a disagreeable impression in my mind 
for some part of the following day. I thought it was worth 
trying whether it was possible to recollect that it was all a 
dream, and that I was in no real danger. I often went to 
sleep with my mind as strongly impressed as I could with 
this thought, that I never in my lifetime was in any real dan- 
ger, and that every fright I had was a dream. After many 
fruitless endeavors to recollect this when the danger appeared, 
I effected it at last, and have often, when I was sliding over 
a precipice into the abyss, recollected that it was all a dream, 
and boldly jumped down. The effect of this commonly was, 
that I immediately awoke. But I awoke calm and intrepid, 
which I thought a great acquisition. After this my dreams 
were never very uneasy, and, in a short time, I dreamt not at 
all." 

Beattie 1 states that he once dreamt that he was walking 
on the parapet of a high bridge. How he came there he did 
not know, but, recollecting that he was not given to such 
pranks, he began to think it might all be a dream, and, find- 
ing his situation unpleasant, and being desirious to get out of 
it, threw himself headlong from the height, in the belief that 
the shock of the fall would restore his senses. The event 
turned out as he anticipated. 

Aristotle also asserts that, when dreaming of danger, he 
used to recollect that he was dreaming, and that he ought not 
to be frightened. 

A still more remarkable narration is that of Gassendi," 
which he thus relates as occurring to himself : 

' ' A good friend of mine, Louis Charambon, judge of the 
criminal court at Digne, had died of the plague. One night, 



" Dissertations, Moral and Critical," London, 1783, art. " Dreaming," p. 222. 
Syntagma philosophicum," pars 71, lib. viii. "Opera omnia," t. i, Lug- 
duni, 1658. 



i u 

2 (( 



THE STATE OF THE MIND DURING SLEEP. 197. 

as I slept, I seemed to see him ; I stretched out my arms to- 
ward him, and said : ' Hail thou who returnest from the place 
of the dead ! ' Then I stopped, reflecting in my dream as fol- 
lows : ' One cannot return from the other world ; I am doubt- 
less dreaming ; but, if I dream, where am I % Not at Paris, 
for I came last to Digne. I am, then, at Digne, in my house, 
in my bedroom, in my bed.' And then, as I was looking for 
myself in the bed, some noise, I know not what, awoke me." 

In all these and like instances it is very probable the indi- 
viduals were much more awake than asleep, for certainly the 
power to judge correctly is not exercised in dreams, involving 
even the most incongruous impossibilities. As Dendy x says, 
" if we know that we are dreaming, the faculty of judgment 
cannot be inert, and the dream would be known to be a fal- 
lacy." There would therefore be no occasion for any such 
management of it as that made use of by Reid and Beattie, or 
for the recollection of Aristotle. The dream and the correc- 
tion of it by the judgment would go together, and there would 
be no self-deception at all — not even for an instant. Dreams 
would accordingly be impossible. The essential feature of 
mental activity during sleep — absolute freedom of the imagina- 
tion — would not exist. 

Relative to G-assendi's case, it is impossible to believe that 
he was fully asleep, and the fact that he was awakened by 
some noise, the nature of which was unrecognized, and which 
was therefore probably slight, tends to support this view. 
Moreover, although he was, as he thought, enabled to detect 
the fallacy of his dream in one respect, his judgment was 
altogether at fault in others. Thus, he had great difficulty in 
making out where he was, and actually so far lost all idea of 
his identity with the person dreaming as to look for himself 
in his own bed ! Certainly an individual whose judgment 
was thus much deranged would scarcely be able to reason cor- 
rectly as to the fact of his dreaming or not, or to question the 
possibility of the dead returning to this world. 

My opinion therefore is, that during sleep the power of 
bringing the judgment into action is suspended. We do not 
actually lose the power of arriving at a decision, but we can- 
not exert the faculty of judgment in accordance with the 
principles of truth and of correct reasoning. An opinion may 
therefore be formed during sleep, but it is more likely to be 

1 "Philosophy of Mystery," London, 1841, p. 208. 



198 SLEEP. 

wrong than right, and no effort that we can make will enable 
ns to distinguish the false from the true, or to discriminate 
between the possible and the impossible. 

That faculty of the mind — the judgment— which when we 
are awake is pre-eminently our guide, can no longer direct 
us aright. The stores of experience go for naught, and the 
mind accepts as truth whatever preposterous thought the im- 
agination presents to it. We are not entirely rendered inca- 
pable of judging, as some authors assert, but the power to 
perceive the logical force of circumstances, to take them at 
their true value and to eliminate error from our mental pro- 
cesses, is altogether arrested, and we arrive at absurd conclu- 
sions from impossible premises. 

But there is no doubt that at times the faculty of judg- 
ment is suspended as regards some parts of our mental oper- 
ations during sleep and this to such an extent that we are, 
like Gassendi in the case quoted, not capable of recognizing 
our own individuality. Thus it is related of Dr. Johnson, 
that he had once in a dream a contest of wit with some other 
person, and that he was very much mortified by imagining that 
his opponent had the better of him. " Now," said he, " one 
may mark here the effect of sleep in weakening the power of 
reflection ; for, had not my judgment failed me, I should have 
seen that the wit of this supposed antagonist, by whose supe- 
riority I felt myself depressed, was as much furnished by me 
as that which I thought I had been uttering in my own char- 
acter." 

Yan Goens dreamt that he could not answer questions to 
which his neighbor gave correct responses. 

An interesting case, in which the judgment was still more 
at fault, has recently come to my knowledge. 

Mrs. C. dreamt that she was Savonarola, and that she 
was preaching to a vast assembly in Florence. Among the 
audience was a lady whom she at once recognized to be her 
own self. As Savonarola, she was delighted at this discovery, 
for she reflected that she was well acquainted with all Mrs'. 
C.'s peculiarities and faults of character, and would therefore 
be enabled to give special emphasis to them in the sermon. 
She did this so very effectively that Mrs. C. burst into a torrent 
of tears, and, with the emotion thus excited, the lady awoke. 
It was some time before she was able to disentangle her mixed- 
up individualities. When she became fully awake she per- 



THE STATE OF THE MIND DURING SLEEP. 199 

ceived that the arguments she had employed to bring about 
the conversion of herself were puerile in the extreme, and 
were directed against characteristics which formed no part of 
her mental organization, and against offences which she had 
not committed. 

Macario 1 makes the following apposite remarks on the 
point under consideration. Keferring to the preposterous 
nature of many dreams, he says : 

" It is astonishing that all these fantastical and impossible 
visions seem to us quite natural, and excite no astonishment. 
This is because the judgment and reflection, having abdicated, 
no longer control the imagination nor co-ordinate the thoughts 
which rush tumultuously through the brain of the sleeper, 
combined only by the power of association. 

"When I say that the judgment and reflection abdicate, it 
should not be inferred that they are abolished and no longer 
exist, for the imagination could not, unaided by the reason, 
construct the whimsical and capricious images of dreams." 

Relative to the power to work out, during sleep, prob- 
lems involving long and intricate mental processes, I have 
already expressed my opinion adversely. In this view I am 
not alone. Rosenkranz, 3 whose contributions to psychological 
science cannot be overestimated, and whose clear and pow- 
erful understanding has rarely been excelled, has pointed out 
how such operations of the understanding are impossible ; for, 
as he remarks, intellectual problems cannot be solved during 
sleep, for such a thing as intense thought, accompanied by 
images, is unknown, while dreams consist of a series of images 
connected by loose and imperfect reasoning. Feuchtersle- 
ben, 3 referring with approval to this opinion of Rosenkranz, 
says that he recollects perfectly having dreamed of such prob- 
lems, and, being happy in their solution, 'endeavored to retain 
them in his memory ; he succeeded, but discovered, on awak- 
ing, that they were quite unmeaning, and could only have 
imposed upon a sleeping imagination. 

Muller 4 says : 

1 Op. cit, p. 286. 

2 " Psychologie ; oder der Wissenschaft von subjectiven Geist," 2ten Auflage? 
Elberfeld, 1843, p. 144. 

3 " The Principles of Medical Psychology," etc., Sydenham Society Transla- 
tion, p. 167. 

4 " Elements of Physiology." Translated from the German, with Notes, by 
William Baly, M. D., etc., London, 1842, vol. ii, p. 1417. 



200 SLEEP. 

" Sometimes we reason more or less correctly in dreams. 
We reflect on problems, and rejoice in their solution. But, 
on awaking from such dreams, the seeming reasoning is fre- 
quently found to have been no reasoning at all, and the solu- 
tion of the problem over which we had rejoiced, to be mere 
nonsense. Sometimes we dream that another person pro- 
poses an enigma ; that we cannot solve it, and that others are 
equally incapable of doing so ; but that the person who pro- 
posed it himself gives the explanation. We are astonished 
at the solution we had so long labored in vain to find. If we 
do not immediately awaken and afterward reflect on this 
proposition of an enigma in our dream, and on its apparent 
solution, we think it wonderful ; but if we awake immedi- 
ately after the dream, and are able to compare the answer 
with the question, we find that it was mere nonsense." 

And in regard to the knowledge that we are dreaming, the 
same author * observes that : 

"The indistinctness of the conception in dreams is gener- 
ally so great that we are not aware that we dream. The phan- 
tasms which are perceived really exist in our organs of sense. 
They afford, therefore, in themselves as strong proof of the 
actual existence of the objects they represent as our own per- 
ceptions of real external objects in the waking state ; for we 
know the latter only by the affections of our senses which they 
produce. When, therefore, the mind has lost the faculty of 
analyzing the impressions on our senses, there is no reason 
why the things which they seem to represent should be sup- 
posed unreal. Even in the waking state phantasms are re- 
garded as real objects when they occur to persons of feeble 
intellect. On the other hand, when the dreaming approaches 
more nearly to the waking state, we sometimes are conscious 
that we merely dream, and still allow the dream to proceed, 
while we retain this consciousness of its true nature." 

Sir Benjamin Brodie, 3 in discussing the subject of wonder- 
ful discoveries made in dreams, and abstruse problems worked 
out, remarks that it would indeed be strange if, among the 
vast number of combinations which constitute our dreams, 
there were not every now and then some having the semblance 
of reality ; and further, that, in many of the stories of great 
discoveries made in dreams, there is much of either mistake or 

1 Op. cit., p. 1418. 

3 " Psychological Inquiries," part i, London, 1856, p. 158. 



THE STATE OF THE MIND DURING SLEEP. 201 

exaggeration, and that, if they could have been written down 
at the time, they would have been found to be worth little 
or nothing. 

Another faculty exercised during sleep has been ascribed 
to the judgment. It is well known that many persons hav- 
ing made up their minds to awake at a certain hour invariably 
do so. I possess this power in a high degree, and scarcely 
ever vary a minute from the fixed time. Just as I go to bed 
I look at my watch and impress upon my mind the figures on 
the dial which represent the hour and minute at which I wish 
to awake. I give myself no further anxiety on the subject, 
and never dream of it, but I always wake at the desired mo- 
ment. 

Now, I cannot conceive what connection the judgment has 
with this power. In the case of alarm-clocks set to go off at a 
certain time, the judgment, as Jouffroy * asserts, may take 
cognizance of the impression made upon the ear, and establish 
the relation between it and the wish to awake at a certain 
time. But in cases where the awaking is the result of an idea 
conceived before going to sleep, and which is not subsequently 
recalled, the judgment cannot act, for this faculty is only ex- 
ercised upon ideas which are submitted to it. The brain is, 
as it were, wound up like the alarm-clock and set to a certain 
hour. When that hour arrives, an explosion of nervous force 
takes place, and the individual awakes. 

Fosgate 2 asserts that the power of judging during sleep is 
probably as good as when we are awake, for decisions are 
made only on the premises presented in either case, and, if 
those in the former condition are absurd or unreasonable, the 
conclusion will likewise be faulty. But this is not very ac- 
curate reasoning ; for it is as much the province of the judg- 
ment to determine the validity of the premises as it is to draw 
a conclusion from them, and, if it cannot recognize the fals- 
ity or truth of propositions the irrational character of which 
would be readily perceived during wakefulness, there is not 
much to be said in favor of its power. 

In fact, however, the conclusions formed in dreams are 
often without any logical relation with the premises. Thus, 

1 "Du sommeil — melanges philosophiques," seconde Edition, Paris, 18S8, 
p. 301. 

a " Sleep psychologically considered with reference to Sensation and Mem- 
ory," New York, 1850, p. 74. 



202 SLEEP. 

when an individual dreams, as in the instance previously- 
quo ted, that he is a column of stone, it is contrary to all ex- 
perience to deduce therefrom the conclusion that he can see 
rocks crumbling around him, and can reflect upon the muta- 
bility of all things. The premise of his being a stone pillar 
being submitted to the judgment, the proper conclusion would 
be that he is composed of inorganic material, is devoid of life, 
and, consequently, not possessed of either sensation or under- 
standing. 

Why the judgment is not properly exercised during sleep 
we do not know. Dr. Philip * believes that in this condition 
ideas flow so rapidly that they are not submitted to the full 
power of the judgment, and that hence the absurdity which 
characterizes them is not perceived. But this explanation is 
by no means satisfactory ; for a merely swift succession of 
ideas is no very serious bar to correct judgment, and when 
the thoughts are as preposterous as those which so often oc- 
cur in dreams, they present no obstacle at all to a proper esti- 
mation of them by the healthy mind. The cause properly re- 
sides in some alteration in the circulation of the blood in that 
part of the brain which presides over the judgment, whereby 
its power is suspended and the imagination left free to fill 
the mind with its incongruous and fantastic images. 

As regards the will, we find very opposite opinions enter- 
tained relative to its activity ; but no one, so far as I am 
aware, appears to have had correct views upon the subject. 
Without going into a full discussion of the views enunciated, 
it will be sufficient to refer to the ideas on the point in ques- 
tion which have been expressed by some of the most eminent 
philosophers and physiologists. 

In the course of his remarks on sleep, Darwin a repeatedly 
alleges that during this condition the action of the will is en- 
tirely suspended ; but he falls into the singular error of con- 
founding volition with the power of motion. Thus he says : 

"When by one continued posture in sleep some uneasy 
sensations are produced, we either gradually awake by the 
exertion of volition, or the muscles connected by habit with 
such sensations alter the position of the body ; but where the 

1 " An Inquiry into the Nature of Sleep and Death," London, 1834, p. 152. 
(Reprinted from tha " Philosophical Transactions " for 1833.) 

a " Zoonomia ; or, The Laws of Organic Life," Am. ed., vol. i, Philadelphia, 
1818, p. 153. 



THE STATE OF THE MIND DURING SLEEP. 203 

sleep is uncommonly profound, and these uneasy sensations 
great, the disease called the incubus or nightmare is pro- 
duced. Here the desire of moving the body is painfully ex- 
erted ; but the power of moving it, or volition, is incapable of 
action till we are awake." 

In consequence of this misapprehension of the nature of 
the will, it is not easy to arrive at Darwin's ideas on the sub- 
ject ; and the attempt is rendered still more difficult from the 
fact that, though he repeatedly states that volition is entirely 
suspended during sleep, he yet in the first part of the fore- 
going quotation makes an individual awake by the gradual 
exercise of the power of the will ; and then in the last part of 
the same paragraph asserts that volition is incapable of action 
till sleep is over. 

Mr. Dugald Stewart * contends that during sleep the power 
of volition is not suspended, but that those operations of the 
mind and body which depend on volition cease to be exer- 
cised. In his opinion the will loses its influence over all our 
powers both of mind and body in consequence of some physi- 
cal alteration in the system which we shall never probably be 
able to explain. To show in full the views of so distinguished 
a philosopher as Mr. Stewart, I quote the following extracts 
from his remarks on the subject : 

"In order to illustrate this conclusion [the one above 
stated] a little further, it may be proper to remark that, if the 
suspension of our voluntary operations in sleep be admitted 
as a fact, there are only two suppositions which can be formed 
regarding its cause. The one is that the power of volition is 
suspended ; the other that the will loses its influence over 
those faculties of the mind and those members of the body 
which during our waking hours are subjected to its authority. 
If it can be shown, then, that the former supposition is not 
agreeable to fact, the truth of the latter seems to follow as 
a necessary consequence. 

"1. That the power of volition is not suspended during 
sleep appears from the efforts which we are conscious of 
making while in that situation. We dream, for instance, 
that we are in danger, and we attempt to call out for assist- 
ance. The attempt, indeed, is in general unsuccessful, and 
the sounds that we emit are feeble and indistinct ; but this 

1 "Elements of the Philosophy of the Human Mind, 1 ' Am. ed., Boston, 1818, 
vol. i, p. 184. 



204 SLEEP. 

only confirms, or rather is a necessary consequence of, the 
supposition that in sleep the connection between the will and 
our voluntary operations is disturbed or interrupted. The 
continuance of the power of volition is demonstrated by the 
effort, however ineffectual. 

" In like manner, in the course of an alarming dream we are 
sometimes conscious of making an exertion to save ourselves 
by flight from an apprehended danger ; but, in spite of all our 
efforts, we continue in bed. In such cases we commonly dream 
that we are attempting to escape and are prevented by some 
external obstacle ; but the fact seems to be that the body is 
at that time not subject to the will. During the disturbed rest 
which we sometimes have when the body is indisposed, the 
mind appears to retain some power over it ; but as even in 
these cases the motions which are made consist rather of a 
general agitation of the whole system than of the regular ex- 
ertion of a particular member of it with a view to produce a 
certain effect, it is reasonable to conclude that in perfectly 
sound sleep the mind, although it retains the power of voli- 
tion, retains no influence whatever over the bodily organs. 

"In that particular condition of the system which is 
known by the name of incubus we are conscious of a total 
want of power over the body ; and I believe the common 
opinion is that it is this want of power which distinguishes 
the incubus from all the other modifications of sleep. But 
the more probable supposition seems to be that every species 
of sleep is accompanied with a suspension of the faculty of 
voluntary motion ; and that the incubus has nothing peculiar 
in it but this — that the uneasy sensations which are produced 
by the accidental posture of the body, and which we find it 
impossible to remove by our own efforts, render us distinctly 
conscious of our incapacity to move. One thing is certain, 
that the instant of our awaking and of our recovering the 
command of our bodily organs is one and the same. 

"2. The same conclusion is confirmed by a different view 
of the subject. It is probable, as was already observed, that 
when we are anxious to procure sleep, the state into which we 
naturally bring the mind approaches to its state after sleep 
commences. Now, it is manifest that the means which nat- 
ure directs us to employ on such occasions is not to suspend 
the powers of volition, but to suspend the exertion of those 
powers whose exercise depends on volition. If it were neces- 



THE STATE OF THE MIND DURING SLEEP. 205 

sary that volition should be suspended before we fall asleep, 
it would be impossible for us by our own efforts to hasten 
the moment of rest. The very supposition of such efforts is 
absurd, for it implies a continued will to suspend the acts of 
the will. 

" According to the foregoing doctrine with respect to the 
state of the mind in sleep, the effort which is produced on our 
mental operations is strikingly analogous to that which is 
produced on our bodily powers. From the observations 
which have been already made, it is manifest that in sleep the 
body is in a very inconsiderable degree, if at all, subject to 
our command. The vital and involuntary motions, however, 
suffer no interruption, but go on as when we are awake, in 
consequence of the operation of some cause unknown to us. 
In like manner it would appear that those operations of the 
mind which depend on our volition are suspended, while cer- 
tain other operations are at least occasionally carried on. 
This analogy naturally suggests the idea that all our mental 
operations which are independent of our will may continue 
during sleep ; and that the phenomena of dreaming may, 
perhaps, be produced by these, diversified in their apparent 
effects in consequence of the suspension of our voluntary 
powers." 

A very little reflection will suffice to convince the reader 
that Mr. Stewart has altogether mistaken the nature of sleep. 
There is no evidence to support his view that the body is 
not subject to the action of the will during sleep. No change 
whatever is induced by this condition in the nerves or mus- 
cles of the organism. The first are just as capable as ever of 
conducting the nervous fluid, and the muscles do not lose any 
of their contractile power. The reason why voluntary move- 
ments are not performed in sleep is simply because the will 
does not act ; and Mr. Stewart is again wrong in asserting 
that volition is not then suspended. We do not will any ac- 
tions when we are asleep. We imagine we do, and that is 
all. The difficulties which encompass us in sleep are, it must 
be recollected, purely imaginary, and the efforts we make to 
escape from them are likewise the products of our fancy. 
Herein lies the main error which Mr. Stewart has committed. 
He appears to accept the dream for a reality, and to regard the 
seeming volitions .which occur in it as actual facts, whereas 
they are all entirely fictitious. 



206 SLEEP. 

An example will serve to make this point still clearer. 

Not long since I dreamed that I stood upon a very high 
perpendicular table-land, at the foot of which flowed a river. 
I thought I experienced an irresistible desire to approach the 
brink and to look down. Had I been awake, such a wish 
would have been the very last to enter my mind, for I have an 
instinctive dread of standing on a height. " I dreamed that I 
threw myself on my face and crawled to the edge of the cliff. 
I looked down at the stream, which scarcely appeared to be 
as wide as my hand, so great was the altitude upon which I 
was placed. As I looked I felt an overpowering impulse to 
crawl still farther and to throw myself into the water below. 
I imagined that I endeavored with all my will to resist this 
force, which appeared to be acting by means altogether exter- 
nal to my organism. My efforts, however, were all in vain. 
I could not control my movements, and gradually I was 
urged farther and farther over the brink, till at last I went 
down into the abyss below. As I struck the water I awoke 
with a start. During my imaginary struggle I thought I 
experienced all the emotions which such an event if real 
would have excited, and I was painfully conscious of my 
utter inability to escape from the peril of my situation. Here 
were circumstances such as, according to Mr. Stewart, demon- 
strate the activity of volition, but at the same time show its 
inability to act upon the body. But clearly they show no 
such thing, for the imaginary volition was to refrain from 
crawling over a precipice which did not exist, and over which, 
therefore, I was not hanging. Such an act of the will, if real, 
could not, in the very nature of the real conditions of the 
situation, have been carried out ; the volition was just as 
imaginary as all the other circumstances of the dream. 

Again, it is not always the case that the imaginary acts of 
the will are not executed during sleep ; and hence it would 
follow from Mr. Stewart's argument that the power of the will 
over the body is not then suspended. Assuming for the mo- 
ment that the volitions of sleep are real, as Mr. Stewart sup- 
poses ; if it can be shown that they are satisfactorily per- 
formed, it results from his line of reasoning that the will has 
power over the body during sleep. Every one who has ever 
dreamed has at times had his will carried out to his entire 
satisfaction. He has ridden horses when pursued, and has 
urged them forward with whip and spur so as to escape from 



THE STATE OF THE MIND DURING SLEEP. 207 

his enemies. Or he has executed the most surprising feats 
both with his mind and body, and has performed voluntary 
deeds which have excited the admiration of all beholders. 
Such acts are, of course, entirely the product of the imagina- 
tion, and all the volitions which accompany them have no 
firmer basis than the unbridled fancy ; but, according to Mr. 
Stewart, they would be evidence of the power of the will over 
the body — a power which in reality does not exist ; not, how- 
ever, as Mr. Stewart supposes, from any impediments in the 
nerves or muscles, but because it is never exerted. 

So far as relates to movements performed during sleep, 
such as turning in bed and assuming more comfortable posi- 
tions, they have nothing whatever to do with the will. They 
are dependent upon the action of the spinal cord, an organ 
that is never at rest, and the functions of which were not 
known as well when Dr. Darwin and Mr. Stewart wrote as 
they are now. The same is true of more complex and longer- 
continued actions, such as those already mentioned of indi- 
viduals riding on horseback, or even walking, during sleep. 

Cabanis " contends that the will is not entirely suspended 
during sleep ; but, as will be perceived from the following 
quotation, he bases his argument upon the fact that move- 
ments are produced which he attributes erroneously to the 
action of the will, but which, like those previously referred 
to, are accomplished by the agency of the spinal cord. He 
says, speaking of the instances of persons walking while 
asleep : 

" These rare cases are not the only ones in which during 
sleep movements are produced by what remains of the will ; 
for it is by virtue of certain direct sensations that a sleeping 
man moves his arm to brush away the flies that may be on 
his face, that he draws up the bedclothes so as to cover him- 
self carefully ; or, as we have already remarked, that he turns 
over and endeavors to find a more comfortable position. It 
is the will which during sleep maintains the contraction of 
the sphincter of the bladder, notwithstanding the effort of the 
urine to escape ; it is the same power which directs the ac- 
tion of the arm in seeking for the vase de nuit, which knows 
where to find it, and enables the individual to use it for sev- 
eral minutes and to return it to its place without being awak- 
ened. Finally, it is not without reason that some physiolo- 
1 Op. cit., t. ii, p. 376, et seq., art. "Du sommeil en particulier." 



208 SLEEP. 

gists have made the will concur in the contraction of several 
muscles, the movements of which are necessary to the main- 
tenance of respiration during sleep." 

All these movements, and many others of a similar charac- 
ter, are entirely spinal, and are altogether independent of cere- 
bral influence. Even when we are awake, we constantly exe- 
cute muscular actions through the power of the spinal cord, 
when the mind is intently occupied with other things. Take, 
for instance, the example of a person playing on the piano, and 
at the same time carrying on a conversation. Here the brain 
is engaged in the one act and the spinal cord in the other. So 
long as the player is not expert in the fingering of the instru- 
ment, he cannot divert his attention from his performance ; 
for the whole power of the mind is required for the proper ap- 
preciation and execution of the music. But after the spinal 
cord has become educated to the habit, and he has attained 
proficiency in the necessary manipulations, the mind is no 
longer required to control the actions, and may be directed to 
other subjects. The arguments of Cabanis, therefore, in favor 
of the partial exercise of the will during sleep, are of no 
force. 

But the power of the will over the muscles of the body is 
only one of the ways in which this faculty is shown. It regu- 
lates the thoughts and the manifestations of emotion when we 
are awake. How utterly incapable it is of any such action 
during sleep we all know. A gentleman, remarkable for the 
ability he possesses for controlling his feelings, tells me that 
when he is asleep he frequently weeps or laughs at imaginary 
events, which, if they really had occurred to him during 
wakefulness, would give rise to no such disturbance. He 
often desires to stop these emotional manifestations, but is 
entirely powerless to do so. Most individuals have had simi- 
lar experiences. 

The theory that the will is in action during sleep is, there- 
fore, to my mind untenable. It has probably had its origin 
in the idea that confounds it with desire, from which it dif- 
fers so markedly that it seems strange the distinction should 
ever fail of being made. Locke ' points out very clearly the 
differences between the two faculties. In fact, they may be 
exerted in directly opposite ways. Desire often precedes vo- 
lition ; but we all, at times, will acts which are contrary to 

1 " An Essay concerning Human Understanding," chap, xxi, section 30. 



THE STATE OF THE MIND DURING SLEEP. 209 

our desire, and desire to perform others which we are unable 
to will. 

. Reid 1 writes with great perspicuity on this distinction be- 
tween desire and will. He says : 

" Desire and will agree in this, that both must have an ob- 
ject of which we must have some conception ; and, therefore, 
both must be accompanied with some degree of understanding. 
But they differ in several things. 

" The object of desire may be anything which appetite, 
passion, or affection leads us to pursue ; it may be any event 
which we think good for us, or for those to whom we are well 
affected. I may desire meat or drink, or ease from pain. 
But to say that I will meat, or will drink, or will ease from 
pain, is not English. There is, therefore, a distinction in com- 
mon language between desire and will. And the distinction 
is, that what we will must be an action, and our own action ; 
what we desire may not be our own action, it may be no action 
at all. 

" A man desires that his children may be happy, and that 
they may behave well. Their being Happy is no action at all ; 
their behaving well is not his action, but theirs. 

" With regard to our own actions, we may desire what we 
do not will, and will what we do not desire ; nay, what we 
have a great aversion to. 

" A man athirst has a strong desire to drink ; but for some 
particular reason he determines not to gratify his desire. A 
judge, from a regard to justice, and to the duty of his office, 
dooms a criminal to die, while, from humanity or particular 
affection, he desires that he should live. A man for health 
may take a nauseous draught, for which he has no desire, but 
a great aversion. Desire, therefore, even when its object is 
some action of our own, is only an incitement to will ; but it 
is not volition. The determination of the mind may be not 
to do what we desire to do. But, as desire is often accompa- 
nied by will, we are apt to overlook the distinction between 
them." 

That desire is manifested during sleep there can be no 
doubt ; and Mr. Stewart, although insisting as he does on the 
distinction between this faculty and volition, confounds them 
in his remarks already quoted. A person suffering from 
nightmare has a most intense desire to escape from his im- 

1 " Essays on the Powers of the Human Mind," vol. iii, Edinburgh, 1803, p. 77. 
14 



210 SLEEP. 

aginary troubles. In my own dream, to which reference has 
been made, my desire to restrain myself from crawling over 
the precipice was exerted to the utmost ; but the will could 
not be brought into action. Darwin, 1 when he says that in 
nightmare " the desire of moving the body is painfully ex- 
erted, but the power of moving it, or volition, is incapable of 
action till we awake," makes the proper distinction between 
desire and will ; but, as I have already shown, confounds the 
latter with another very different faculty. 

From the foregoing observations it will be seen that during 
sleep the three great divisions of the mind are differently 
affected. 

1. Feeling, embracing sensation and emotion, is suspended, 
so far as the first is concerned ; but is in full action as regards 
the second. We do not see, hear, smell, taste, or enjoy the 
sense of touch in sleep, although the brain may be aroused 
into activity and we may awake through the excitations con- 
veyed to it by the special senses. The emotions have full 
play, unrestrained by the will, and governed only by the 
imagination. 

2. The Will or Volition is entirely suspended. 

3. The Thought or Intellect is variously affected in its dif- 
ferent powers. The imagination is active, and the memory 
may be exercised to a great extent ; but the judgment, per- 
ception, conception, abstraction, and reason are weakened, 
and sometimes altogether lost. 



CHAPTER V. 

THE PHYSIOLOGY OF DREAMS. 

The subject of the foregoing chapter is so intimately con- 
nected with the phenomena of dreaming, and I have expressed 
my views in regard to it at such length, that but few psycho- 
logical points remain to be considered in the present discus- 
sion. What I have to say, therefore, in regard to the physiol- 
ogy of dreaming must be read in connection with the chapter 
on "The State of the Mind during Sleep," in order that the 
whole matter may be fully understood. 

1 Op. cit., p. 155. 



THE PHYSIOLOGY OF DREAMS. 211 

It is contended by some writers that the mind is never at 
rest, and that even during the most profound sleep dreams 
take place, which are either forgotten immediately, or which 
make no impression on the memory. That this view is erro- 
neous is, I think, very evident. If it were correct, the first 
object of sleep — rest for the brain — would not be attained. 
We all know how fatigued we are, and how indisposed to 
exertion the brain is, after a night of continued dreaming, and 
we can easily imagine what would be the consequences if 
such a condition were kept up night after night. To say that 
we really do dream not only every night, but every instant of 
the night — in fact, always and continually when we sleep — but 
that we forget our dreams as soon as they are formed, remem- 
bering solely those which are most vivid, is making assertions 
which not only are without proof, but which are impossible 
of proof. For, if, as Locke * remarks, the sleeping man on 
awaking has no recollection of his thoughts, it is very certain 
that no one else can recollect them for him. 

The observations of Locke on this point are extremely ap- 
propriate, and, to my mind, very philosophical and logical. 
After insisting that, sleeping or waking, a man cannot think 
without being sensible of it, he says : a 

"I grant that the soul of a waking man is never without 
thought, because it is the condition of being awake ; but 
whether sleeping without dreaming be not an affection of the 
whole man, mind as well as body, may be worth a waking 
man's consideration, it being hard to conceive that anything 
should think and not be conscious of it. If the soul doth 
think in a sleeping man without being conscious of it, I ask, 
whether during such thinking it has any pleasure or pain, or 
be capable of happiness or misery ? I am sure the man is not, 
any more than the bed or earth he lies on, for to be happy or 
miserable without being conscious of it seems to me utterly 
inconsistent and impossible. Or if it be possible that the soul 
can, while the body is sleeping, have its thinkings, enjoy- 
ments, and concerns, its pleasure or pain, about which the 
man is not conscious of nor partakes in, it is certain that Soc- 
rates asleep and Socrates awake is not the same person ; but 
his soul when he sleeps and Socrates the man, consisting of 
body and soul when he is waking, are two persons, since wak- 

1 " An Essay concerning the Human Understanding," book ii, section 17. 
a Op. et loc. cit., section 11. 



212 SLEEP. 

ing Socrates has no knowledge of or concernment for that 
happiness or misery of his soul which it enjoys alone by itself 
while he sleeps without perceiving anything of it, any more 
than he has for the happiness or misery of a man in the Indies 
whom he knows not ; for if we take wholly away all con- 
sciousness of our actions and sensations, especially of pleasure 
and pain, and the concernment that accompanies it, it will be 
hard to know wherein to place personal identity." 

In a subsequent section of the same chapter Locke asserts 
that most men pass a great part of their lives without dream- 
ing, and that he once knew a scholar who had no bad memory, 
who told him he had never dreamed in his life till after the 
occurrence of a fever in the twenty -fifth or twenty-sixth year 
of his age. 

Examples of persons who have not ordinarily dreamed are 
adduced by the ancient writers. Pliny ' refers to men who 
never dreamed. Plutarch 8 alludes to the case of Cleon, who, 
in living to an advanced age, had yet never dreamed ; and 
Suetonius s declares that before the murder of his mother Nero 
had never dreamed. 

A lady who was under my care for a serious nervous affec- 
tion declared to me that she never had had but one dream in 
her life, and that was after receiving a severe fall in which she 
struck her head. 

And yet, notwithstanding the experience of every one 
that sleep often happens without the accompaniment of 
dreams, the great majority of writers hold the view that the 
brain is never at rest. Doubtless this opinion has its origin 
partly in the doctrine that the mind is a something altogether 
independent of and superior to the brain. They appear to be 
incapable of appreciating the fact that when the brain is in a 
state of complete repose there can be no mental manifestation, 
and that all intellectual phenomena are the results of cerebral 
activity. Another cause for their belief is the fact that they 
make no distinction between dreaming and thinking, whereas 
it is very evident that the two are not to be placed in the same 
category. Thinking is an action which requires cerebral ef- 
fort, and which is undertaken with a determinate purpose. 
We will to think, and we think what we please ; but it is very 

1 "Historia naturalis," lib. x, cap. lxxv, "De somno animalium." 

2 " De defectu oraculorum." 

8 "De vita xii. Ca3sarum," "Nero," cap. xlvi. 



THE PHYSIOLOGY OF DREAMS. 213 

different with our dreams, which come and go without any 
power on our part to regulate or direct them. To think re- 
quires all the faculties of the mind ; to dream necessitates 
only the memory and the imagination. In thinking, the 
brain is active in all its parts ; in dreaming, it is nearly en- 
tirely quiescent. 

Writers who contend for the doctrine of constant mental 
activity regard the brain as the organ or tool of the mind, a 
structure which the mind makes use of in order to manifest 
itself. Such a theory is certain to lead them into difficulties, 
and is contrary to all the teaching of physiology. The full dis- 
cussion of this question would be out of place here ; I will, 
therefore, only repeat what has been said in the first chapter, 
that this work is written from the stand-point of regarding the 
mind as nothing more than the result of cerebral action. Just 
as a good liver secretes good bile, a good candle gives good 
light, and good coal a good fire, so does a good brain give a 
good mind. When the brain is quiescent there is no mind. 

Lemoine 1 begins his chapter "On the State of the Mind 
during Sleep " with the assertion that "there is no sleep for 
the mind." He is obliged, however, to admit that, "when the 
organs of the body are benumbed by sleep, the mind appears 
to be in a particular state ; it seems to be submitted to other 
laws than those which govern it during wakefulness ; it seems 
to have lost for a time its most precious faculties." 

During sleep the mind is, as he supposes, in a particular 
state, for, as has been shown in the previous chapter, it has 
lost many of its chief parts. The laws which govern it are, 
however, the same which always regulate it. The body from 
which its power is primarily derived — the brain — is not in 
the same condition during sleep as during wakefulness, and 
hence the differences in the evidences of cerebral activity. 

Sir William Hamilton a is generally considered to have de- 
termined affirmatively the question of the continuance of the 
action of the brain during sleep. He caused himself to be 
aroused from sleep at intervals through the night, and inva- 
riably found that he was disturbed from a dream, the particu- 
lars of which he could always distinctly recollect. But a full 
knowledge of the subject he was investigating would have 
sufficed to convince Sir William that the conclusion he drew 
from his experiments was altogether fallacious. It is well 
1 Op. cit., p. 63. 2 " Lectures on Metaphysics," vol. i, p. 323. 



214 SLEEP. 

known that dreams are excited by strong impressions made 
upon the senses, or by irritations arising in the internal organs. 
Thus Baron Trenck relates that when confined in his dungeon 
he suffered the pangs of hunger almost continually, and that 
his dreams at night were always of delicate meats and sump- 
tuous repasts, spread before him on luxuriously furnished 
tables. The mere excitation of waking a sleeping person is 
generally sufficient to give rise to a dream. Maury, in his very 
interesting work, to which reference has already been made, 
and which will hereafter be more specifically considered, ad- 
duces many examples of dreams produced by sensorial im- 
pressions. I have myself performed many experiments with 
reference to this point, and have generally found ample con- 
firmation of Maury' s investigations. It may therefore, I think, 
be assumed, without any violence to the actual facts of the 
cases, that the brain is not always in action, and that there 
are times when we sleep without dreaming. 

In the previous chapter the idea is sought to be conveyed 
that we originate nothing in our dreams. We may conceive 
of things which never existed, or of which we have heard or 
read, but the images we make of them are either composed of 
elements familiar to us, or else are based upon ideal representa- 
tions which we have formed in our waking moments. Thus, 
before the discovery of America no Europeans ever dreamed 
of American Indians, for the reason that nothing existed 
within their knowledge which could give any idea of the ap- 
pearance of such human beings. It is possible that Colum- 
bus and his companions may have dreamed of the continent 
of which they were in search, and of its natives, but the images 
formed of the latter must necessarily have resembled other 
beings they had seen, or which they had heard described. 
After the discovery, however, it was no unusual thing for the 
Spaniards and others to have correct images of Indians appear 
to them in their dreams. 

Dreams, therefore, must have a foundation, and this is 
either impressions made upon the mind at some previous 
period, or produced during sleep by bodily sensations. These 
impressions, however they may be formed, are subjected to 
the unrestrained influence of the imagination. 

At first sight it may seem that we often have dreams not 
excited by actual sensations, and which have no relation to 
any events of our lives, or any ideas which have passed 



THE PHYSIOLOGY OF DREAMS. 215 

through our minds, but thorough investigation will invariably 
reveal the existence of an association between the dream and 
some such ideas or events. For instance, some time ago I 
dreamed that a gentleman, a friend of mine, had invented 
what he called a " dog-cart ambulance," a vehicle which he 
declared was the best ever made for the transportation of sick 
or wounded men. On awaking, all the particulars were fresh 
in my mind, but I could not for some time perceive why I had 
had such a dream. At last I recollected that the morning 
before a gentleman had given me a very full description of 
Prospect Park, in Brooklyn. The friend of whom I dreamed 
has charge of the construction of this park. His presence 
was, therefore, fully explained, and, as dog-carts are driven in 
parks, this link was also accounted for. The ambulance part 
was due to the fact that I had that same morning found the 
card of a gentleman upon my table who really had invented 
an ambulance. The imagination had, therefore, taken these 
data supplied by the memory, and had combined them into 
the incongruous web constituting my dream. 

Dreams are also frequently built upon circumstances which 
have occurred many years previously, and which have long 
since apparently passed from our recollection. A very strik- 
ing instance of this kind is related by Abercrombie, ■ on the 
authority of Sir Walter Scott. 

"Mr. R. J. Rowland, a gentleman of landed property in 
the vale of Gala, was prosecuted for a very considerable sum, 
the accumulated arrears of teind (tithe), for which he was said 
to be indebted to a noble family the titulars (lay impropria- 
tors of the tithe). Mr. R. was strongly impressed with the be- 
lief that his father had, by a form of process peculiar to the 
law of Scotland, purchased these teinds from the titular, and, 
therefore, that the present prosecution was groundless. But, 
after an industrious search among his father' s papers, an in- 
vestigation of the public records, and a careful inquiry among 
all persons who had transacted law business for his father, no 
evidence could be discovered to support his defence. The 
period was now near at hand when he conceived the loss of 
his lawsuit to be inevitable, and he had formed his determina- 
tion to ride to Edinburgh next day and make the best bar- 
gain he could in the way of compromise. He went to bed 

1 " Inquiries concerning the Intellectual Powers and the Investigation of 
Truth," tenth edition, London, 1840, p. 283. 



216 SLEEP. 

with this resolution, and, with all the circumstances of the 
case floating upon his mind, had a dream to the following 
purpose. His father, who had been many years dead, ap- 
peared to him, he thought, and asked him why he was dis- 
turbed in his mind. In dreams men are not surprised at such 
apparitions. Mr. R. thought that he informed his father of 
the cause of his distress, adding that the payment of a con- 
siderable sum of money was the more unpleasant to him be- 
cause he had a stray consciousness that it was not due, though 
he was unable to recover any evidence in support of his belief. 
' You are right, my son,' replied the paternal shade ; 'I did 
acquire right to these teinds, for payment of which you are 
now prosecuted. The papers relating to the transaction are in 
the hands of Mr. , a writer (or attorney), who is now re- 
tired from professional business, and resides at Inveresk, near 
Edinburgh. He was a person whom I employed on that oc- 
casion for a particular reason, but who never, on any other 
occasion, transacted business on my account. It is very pos- 
sible^ pursued the vision, i that Mr. may have forgotten a 

matter which is now of a very old date ; but you may call it 
to his recollection by this token — that when I came to pay 
his account there was difficulty in getting change for a Por- 
tugal piece of gold, and that we were forced to drink out the 
balance at a tavern.' 

"Mr. R. awoke in the morning with all the events of the 
vision impressed on his mind, and thought it worth while to 
ride across the country to Inveresk, instead of going straight 
to Edinburgh. When he came there he waited on the gentle- 
man mentioned in the dream, a very old man ; without say- 
ing anything of the vision, he inquired whether he remem- 
bered having conducted such a matter for his deceased father, 
The old gentleman could not at first bring the circumstance 
to his recollection, but, on mention of the Portugal piece of 
gold, the whole returned upon his memory ; he made an im- 
mediate search for the papers and recovered them, so that 
Mr. R. carried to Edinburgh the documents necessary to gain 
the cause which he was on the verge of losing." 

A friend has related to me some circumstances in his own 
case similar to the above, and illustrating the same points. 
In the course of his practice as a lawyer it became necessary 
for him to ascertain the exact age of a client, who was also 
his cousin. Their grandfather had been a rather eccentric 



THE PHYSIOLOGY OF DKEAMS. 217 

personage, who had taken a great deal of notice of both his 
grandsons — his only direct descendants. He died when they 
were boys. My friend often told his consin that if his grand- 
father were alive there wonld be no difficulty at getting at 
the desired information, and that he had a dim recollection of 
having seen a record kept by the old gentleman, and of there 
being some peculiarity about it which he could not recall. 
Several months elapsed, and he had given up the idea of at- 
tempting to discover the facts of which he had been in search, 
when, one night, he dreamed that his grandfather came to 

him and said : " You have been trying to find out when J 

was born ; don' t you recollect that one afternoon when we 
were fishing I read you some lines from an Elzevir Horace, 
and showed you how I had made a family record out of the 
work by inserting a number of blank leaves at the end \ Now, 

as you know, I devised my library to the Rev. . I 

was a d d fool for giving him books which he will never 

read ! Get the Horace, and you will discover the exact hour 
at which J was born." In the morning all the particu- 
lars of this dream were fresh in my friend's memory. The 
reverend gentleman lived in a neighboring city ; my friend 
took the first train, found the copy of Horace, and at the end 
the pages constituting the family record, exactly as had been 
described to him in the dream. By no effort of his memory, 
however, could he recollect the incidents of the fishing excur- 
sion. 

Dr. Macnish, l in stating his opinion that dreams are uni- 
formly the resuscitation or re-embodiment of thoughts which 
have formerly, in some shape or other, occupied the mind, re- 
lates the following example from his own experience : 

" I lately dreamed that I walked upon the banks of the 
great canal in the neighborhood of Glasgow. On the side op- 
posite to that on which I was, and within a few feet of the 
water, stood the splendid portico of the Eoyal Exchange. A 
gentleman whom I knew was standing upon one of the steps, 
and we spoke to each other. I then lifted a large stone and 
poised it in my hand, when he said that he was certain I 
could not throw it to a certain spot, which he pointed out. I 
made the attempt, and fell short of the mark. At this mo- 
ment a well-known friend came up whom I knew to excel at 
putting the stone ; but, strange to say, he had lost both his 

1 Op. cit., p. 10. 



218 SLEEP. 

legs, and walked upon wooden substitutes. This struck me 
as exceedingly curious, for my impression was that he had 
only lost one leg, and had but a single wooden one. At my 
desire he took up the stone, and, without difficulty, threw it 
beyond the point indicated by the gentleman upon the oppo- 
site side of the canal. The absurdity of this dream is ex- 
tremely glaring, and yet, on strictly analyzing it, I find it to 
be wholly composed of ideas which passed through my mind 
on the previous day, assuming a new and ridiculous arrange- 
ment. I can compare it to nothing but to cross-reading in 
the newspapers, or to that well-known amusement which con- 
sists in putting a number of sentences, each written on a sepa- 
rate piece of paper, into a hat, shaking the whole, then tak- 
ing them out, one by one, as they come, and seeing what kind 
of medley the heterogeneous compound will make when thus 
fortuitously put together. For instance, I had, on the above 
day, taken a walk to the canal along with a friend. On re- 
turning from it, I pointed out to him a spot where a new road 
was forming, and where, a few days before, one of the work- 
men had been overwhelmed by a quantity of rubbish falling 
upon him, which fairly chopped off one of his legs, and so 
much damaged the other that it was feared amputation would 
be necessary. Near this very spot there is a park, in which, 
about a month previously, I practiced throwing the stone. 
On passing the Exchange, on my way home, I expressed re- 
gret at the lowness of its situation, and remarked what a fine 
effect the portico would have were it placed upon more ele- 
vated ground. Such were the previous circumstances, and 
let us see how they bear upon the dream. In the first place, 
the canal appeared before me. 2. Its situation is an elevated 
one. 3. The portico of the Exchange occurring to my mind as 
being placed too low became associated with the elevation of 
the canal, and I placed it close by on a similar altitude. 4. 
The gentleman I had been walking with was the same whom 
in the dream I saw standing upon the steps of the portico. 5. 
Having related to him the story of the man who lost one limb 
and had a chance of losing another, this idea brings before 
me a friend with a pair of wooden legs who, moreover, ap- 
pears in connection with putting the stone, as I knew him to 
excel at that exercise. There is only one other element in 
the dream which the preceding events will not account for, 
and that is the surprise at the individual referred to having 



THE PHYSIOLOGY OF DREAMS. 219 

more than one wooden leg. But why should he have even 
one, seeing that in reality he is limbed like other people ? 
This also I can account for. Two years ago he slightly in- 
jured his knee while leaping a ditch, and I remember jocu- 
larly advising him to get it cut off. I am particular in illus- 
trating this point with regard to dreams, for I hold that, if it 
were possible to analyze them all, they would invariably be 
found to stand in the same relation to the waking state as 
the above specimen. The more diversified and incongruous 
the character of a dream, and the more remote from the 
period of its occurrence the circumstances which suggested it, 
the more difficult does its analysis become ; and, in point of 
fact, this process may be impossible, so totally are the ele- 
ments of the dream often dissevered from their original sense, 
and so ludicrously huddled together." 

A dream which Professor Maas, 1 of Halle, relates as having 
occurred to himself affords an excellent example of the de- 
pendence of dreams upon actual events, and shows how these 
latter are distorted and perverted by the imagination of the 
sleeper. 

"I dreamed once," he says, "that the Pope visited me. 
He commanded me to open my desk, and he carefully ex- 
amined all the papers it contained. While he was thus em- 
ployed, a very sparkling diamond fell out of his triple crown 
into my desk, of which, however, neither of us took any 
notice. As soon as the Pope had withdrawn I retired to bed, 
but was soon obliged to rise on account of a thick smoke, the 
cause of which I had yet to learn. Upon examination, I dis- 
covered that the diamond had set fire to the papers in my 
desk and burned them to ashes." 

In analyzing the circumstances which gave rise to this 
dream, Professor Maas relates the following events, which 
constituted its basis : 

" On the preceding evening I was visited by a friend with 
whom I had a lively conversation upon Joseph IPs suppres- 
sion of monasteries and convents. With this idea, though 
I did not become conscious of it in the dream, was associated 
the visit which the Pope publicly paid the Emperor Joseph, 
at Yienna, in consequence of the measures taken against the 
clergy ; and with this again was combined, however faintly, 
the representation of the visit which had been paid me by my 
1 Quoted in Dendy's " Philosophy of Mystery," London, 1841, p. 225. 



220 SLEEP. 

friend. These two events were, by the snbreasoning faculty, 
compounded into one, according to the established rule — that 
things which agree in their parts also correspond as to the 
whole ; hence the Pope's visit was changed into a visit paid 
to me. The subreasoning faculty, then, in order to account 
for this extraordinary visit, fixed upon that which was the 
most important object in my room — namely, the desk, or 
rather the papers which it contained. That a diamond fell 
out of the triple crown was a collateral association, which was 
owing merely to the representation of the desk. Some days 
before, when opening the desk, I had broken the crystal of 
my watch, which I held in my hand, and the fragments fell 
among the papers ; hence no further attention was paid to 
the diamond being a representation of a collateral series of 
things. But afterward the representation of the sparkling 
stone was again excited, and became the prevailing idea ; 
hence it determined the succeeding association. On account 
of its similarity it excited the representation of fire, with 
which it was confounded ; hence arose fire and smoke. But 
in the event the writings only were burned, not the desk it- 
self, to which, being of comparatively little value, the atten- 
tion was not directed." 

Feuchtersleben 1 takes the same view of dreaming as that 
enunciated in this chapter. Thus he says : 

" Dreaming is nothing more than the occupation of the 
mind in sleep with the pictorial world of fancy. As the 
closed or quiescent senses afford it no materials, the mind, 
ever active, must make use of the store which memory re- 
tains ; but as its motor influence is likewise organically im- 
peded, it cannot independently dispose of this store. Thus 
arises a condition in which the mind looks, as it were, on the 
play of the images within itself, and manifests only a faint or 
partial reaction." 

Locke 2 contends that "the dreams of a sleeping man are 
all made up of the waking man's ideas oddly put together." 

Observation and reflection show us that the mind origi- 
nates nothing during sleep ; it merely remembers — and often 
in the most chaotic manner — the thoughts, the fancies, the 
impressions which have been imagined or received by the 

1 "The Principles of Medical Psychology," etc., Sydenham Society Transla- 
tion, London, 1847, p. 163. 

2 Op. cit., book ii, section 17. 



THE PHYSIOLOGY OF DREAMS. 221 

individual when awake. Sometimes ideas are reproduced in 
dreams exactly as they have occurred to us in our waking 
moments, and this may take place night after night with 
scarcely the alteration of a single circumstance. A friend 
informs me that he is very subject to dreams of this character, 
and that on some occasions the repetition has taken place as 
many as a dozen times. 

A very striking instance of this kind occurred to me a few 
years since, and made a deep impression on my mind. I had 
just read Schiller's ode to Laura, as translated by Sir E. Bul- 
wer Lytton, beginning, 

" Who and what gave to me the wish to woo thee ? " 
and admired it as a striking piece of versification, conveying 
some noted philosophical ideas in a forcible and beautiful 
manner. The following night I had a very vivid dream of a 
condition of pre-existence, in which I imagined myself to be. 
The connection between the dream and the poem I had been 
reading was sufficiently well marked, and did not astonish 
me. I was, however, surprised to find that the next night I 
had exactly the same dream, and that it was repeated three 
times subsequently on consecutive nights. 

The dependence of dreams upon ideas which we have had 
when awake was well known to the ancients. Thus Lucius 
Accius, ' a poet who lived more than a hundred and fifty years 
before the Christian era, says : 

"Quae in vita usurpant homines, cogitant, curant, vident 
Quaeque agunt vigilantes, agitantque casi cui in somno acci- 
dant, 
Minus mirum est." 

Lucretius 2 declares that during sleep we are amused with 
things which have made us weep when awake ; that circum- 
stances which have pleased us are recalled to our minds ; that 
objects are presented to us which occupied our thoughts long 
before ; and that recent events appear still more vividly be- 
fore us. 

Petronius Arbiter 3 cites Epicurus to the same effect. Try- 
phsena having declared that she had had a dream in which 
there appeared to her the image of Neptune she had seen at 
Baise, "Hence you may perceive," observed Eumolpus, "what 

1 Cited by M. l'Abbe Eichard in "La Theorie des Songes," Paris, 1766, p. 32. 

2 " De Eermn Natura," 1. iv, v. 959. 

3 " Satyricon," Bonn's edition, London, 1854, p. 307. 



222 SLEEP. 

a divine man is Epicurus, who so ingeniously ridiculed these 
sports of fancy. 
" ' When in a dream presented to our view 
Those airy forms appear so like the true, 
No prescient shrine, no god the vision sends, 
But every breast its own delusion lends. 
For when soft sleep the body wraps in ease, 
And from the inactive mass the fancy frees, 
What most by day affects, at night returns ; 
Thus he who shakes proud states, and cities burns, 
Sees showers of darts, forced lines, disordered wings, 
Blood-reeking fields, and deaths of vanquished kings ; 
He that by day litigious knots untied, 
And charmed the drowsy bench to either side, 
By night a crowd of cringing clients sees, 
Smiles on the fools and kindly takes their fees ; 
The miser hides his wealth, new treasure finds ; 
Through echoing woods his horn the huntsman winds ; 
The sailor's dream wild scenes of wreck describes ; 
The wanton lays her snares ; the adulteress bribes ; 
Hounds in full cry, in sleep, the hare pursue ; 
And hapless wretches their old griefs renew.'" 1 
It is related of an ancient tyrant that one of his courtiers 
described to him a dream in which the courtier had assassi- 
nated his master. "You could not," exclaimed the tyrant, 
"have dreamed this without having previously thought of 
it, " and then ordered his immediate execution. 

Now, besides this foundation of dreams upon circumstances 
which have happened during our waking moments, they may 
arise, as has already been intimated, from impressions made 
upon the mind during sleep. Sensations may be so intense as 
to be partially appreciated by the brain, and yet not strong 
enough to cause sleep to be interrupted. In such cases the 
imagination seizes the imperfect perception and weaves it into 
a tissue of incongruous fancies, which, however, generally 
bear a more or less definite relation to the character of the 
sensorial impression. Many examples of dreams thus pro- 
duced are on record, and many others have come under my 
own observation. The interest which attaches to phenomena 

1 In the above quotation I have slightly altered Kelly's version in Bonn's 
edition of Petronius. The original Latin is fully as forcible and true to nature as 
the translation. 



THE PHYSIOLOGY OF DREAMS. 223 

of this character must be my excuse for quoting some of the 
more remarkable instances of this kind which have been 
brought to my attention. 

The following are related by Abercrombie : ' 

During the alarm excited in Edinburgh by the apprehen- 
sion of a French invasion, almost every man was a soldier, and 
all things had been arranged in expectation of the landing of 
the enemy. The first notice was to be given by the firing of a 
gun from the castle, and this was to be followed by a chain 
of signals calculated to arouse the country. The gentleman 
to whom the dream occurred was a zealous volunteer, and, 
being in bed between two and three o'clock in the morning, 
dreamt of hearing the signal gun. He imagined that he went 
at once to the castle, witnessed the proceeding for displaying 
the signals, and saw and heard all the preparations for the 
assemblage of the troops. At this time he was roused by his 
wife, who awoke in a fright, in consequence of a similar 
dream. The origin of both dreams was ascertained in the 
morning to be the noise produced by the falling of a pair of 
tongs in the room above. 

A gentleman dreamt that he had enlisted as a soldier, 
joined his regiment, deserted, was apprehended, carried back, 
condemned to be shot, and at last led out to execution. At 
this instant a gun was fired, and he awoke, to find that a noise 
in the adjoining room had both produced the dream and 
awakened him. 

The next is a very extraordinary case. 

The subject was an officer in the expedition to Louisburg, 
in 1758. During his passage in the transport his companions 
were in the habit of amusing themselves at his expense. They 
could produce in him any kind of dream by whispering in 
his ear, especially if this was done by a friend with whose 
voice he was familiar. Once they conducted him through 
the whole process of a quarrel which ended in a duel, and 
when the parties were supposed to have met, a pistol was put 
into his hand, which he fired, and was awakened by the re- 
port. On another occasion they found him asleep on the top 
of a locker in the cabin, when they made him believe he had 
fallen overboard, and exhorted him to save himself by swim- 
ming. Then they told him that a shark was pursuing him, 
and entreated him to dive for his life. He instantly did so, 

1 Op. cit., p. 275, et seq. 



224 SLEEP. 

and with so much force as to throw himself from the locker 
upon the cabin floor, by which he was much bruised, and 
awakened, of course. After the landing of the army at Louis- 
burg, his friends found him one day asleep in his tent, and 
evidently much annoyed by the cannonading. They then 
made him believe that he was engaged, when he exhibited 
great fear, and showed a decided disposition to run away. 
Against this they remonstrated, but at the same time in- 
creased his fears by imitating the groans of the wounded and 
the dying ; and when he asked, as he often did, who was hit, 
they named his particular friends. At last they told him that 
the man next himself in his company had fallen, when he in- 
stantly sprang from his bed, rushed out of his tent, and was 
roused from his danger and his dream by falling over the 
tent- cords. 

A friend informs me that he has a brother who will carry 
on a conversation with any person who whispers to him in his 
sleep, and that his emotions are then very readily excited by 
any pitiful story that may be told him. Upon awaking, he 
has a distinct recollection of his dreams, which are always 
connected with the ideas communicated. 

I recollect very distinctly the particulars of a dream which 
I had several years since, and which was due to an impres- 
sion conveyed to the brain through the ear. The dream also 
illustrates the point previously brought forward, that a defi- 
nite conception of time does not enter into the phenomena of 
dreams. 

I dreamed that I had taken passage in a steamboat from 
St. Louis to New Orleans. Among the passengers was a man' 
who had all the appearance of being very ill with consump- 
tion. He looked more like a ghost than a human being, and 
moved noiselessly among the passengers, noticing no one, 
though attracting the attention of all. For several days 
nothing was said between him and any one, till one morning, 
as we approached Baton Rouge, he came to where I was sit- 
ting on the guards and began a conversation by asking me 
what time it was. I took out my watch, when he instantly 
took it from my hand and opened it. "I too once had a 
watch," he said; "but see what I am now." With these 
words he threw aside the large cloak he habitually wore, and 
I saw that his ribs were entirely bare of skin and flesh. He 
then took my watch, and, inserting it between his ribs, said 



THE PHYSIOLOGY OF DREAMS. 225 

it would make a very good heart. Continuing his conversa- 
tion, he told me that he had resolved to blow up the vessel the 
next day, but that, as I had been the means of supplying him 
with a heart, he would save my life. "When you hear the 
whistle blow," he said, "jump overboard, for in an instant 
afterward the boat will be in atoms." I thanked him, and 
he left me. All that day and the next I endeavored to ac- 
quaint my fellow-passengers with the fate in store for them, 
but discovered that I had lost the faculty of speech. I tried 
to write, but found that my hands were paralyzed. In fact, 
I could adopt no means to warn them. While I was making 
these ineffectual efforts, I heard the whistle of the engine ; I 
rushed to the side of the boat to plunge overboard, and awoke. 
The whistle of a steam saw-mill near my house had just 
begun to sound, and had awakened me. My whole dream 
had been excited by it, and could not have occupied more 
than a few seconds. 

The following account 1 shows how a dream may be set in 
action by the sense of smell. 

"On one occasion during my residence at Birmingham I 
had to attend many patients at Coventry, and for their ac- 
commodation I visited that place one day in every week. My 
temporary residence was a druggist's shop in the market- 
place. Having on one occasion, now to be mentioned, a more 
than usual number of engagements, I was obliged to remain 
one night, and a bed was provided for me at the residence of 
a cheese-monger in the same locality. The house was very 
old, the rooms very low, and the street very narrow. It was 
summer-time, and during the day the cheese-maker had un- 
packed a box or barrel of strong old American cheese ; the very 
street was impregnated with the odor. At night, jaded with 
my professional labors, I went to my dormitory, which seemed 
filled with a strong, cheesy atmosphere, which affected my 
stomach greatly, and quite disturbed the biliary secretions. 
I tried to produce a more agreeable atmosphere to my olfac- 
tory sense by smoking cigars, but did not succeed. At length, 
worn out with fatigue, I tried to sleep, and should have suc- 
ceeded, but for a time another source of annoyance prevented 
me doing so ; for in an old wall behind by head, against 
which my ancient bed stood, there were numerous rats gnaw- 
ing away in real earnest, The crunching they made was in- 

1 Journal of Psychological Medicine, July, 1856. 
15 



226 SLEEP. 

deed terrific, and I resisted the drowsy god from a dread that 
these voracious animals would make a forcible entrance, and 
might take personal liberties with my flesh. 

" But at length ' tired nature ' ultimately so overpowered me 
that I slept in a sort of fever. I was still breathing the cheesy 
atmosphere, and this, associated with the marauding rats, so 
powerfully affected my imagination that a most horrid dream 
was the consequence. I fancied myself in some barbarous 
country, where, being charged with a political offence, I was 
doomed to be incarcerated in a large cheese. And although 
this curious prison-house seemed most oppressive, it formed 
but part of my sufferings ; for scarcely had I become recon- 
ciled to my probable fate than, to my horror, an army of rats 
attacked the monster cheese, and soon they seemed to have 
effected an entrance, and began to ^x. themselves in numbers 
upon my naked body. The agony I endured was increased 
by the seeming impossibility to drive them away, and, for- 
tunately for my sanity, I awoke, but with a hot head and 
throbbing temples, and a sense of nausea from the extremely 
strong odor of the cheese." 

I have on two occasions that I recollect had dreams which 
were due to odors. On one of them, the smell of gas escaping 
in the room excited the dream of a chemical laboratory ; on 
the other, the smell of burning cloth caused me to dream of a 
laundry, and of one of the women ironing a blanket, which 
she scorched with a hot iron. A lady informs me that a simi- 
lar odor produced in her a dream of the house being on fire, 
and the impossibility of her escaping by reason of all her 
clothes being burned up. 

Dreams are very readily excited through impressions made 
on the special nerves of sensation. Instances are given of 
persons sleeping with bottles of hot water applied to their 
feet dreaming of walking on burning lava, or some other hot 
substance. A patient related to me the particulars of a dream 
which occurred to him while he was asleep with a vessel of 
hot water applied to the soles of his feet. He had, just before 
going to sleep, read in the evening paper an account of the 
capture of an English gentleman by Italian brigands. He 
dreamt that while crossing the Rocky Mountains he had been 
attacked by two Mexicans, who, after a long fight, had suc- 
ceeded in taking him alive. They conveyed him very hur- 
riedly to their camp, which was situated in a deep gorge. 



THE PHYSIOLOGY OF DREAMS. 227 

Here they told him that, unless he revealed to them the means 
of making gold from copper, they would submit him to tor- 
ture. In vain he pleaded ignorance of any such process. 
Pulling off his boots and stockings, they held his naked feet 
to the fire till he shrieked with agony, and awoke to find that 
the blanket which was wrapped around the tin vessel contain- 
ing the hot water had become disarranged, and that his feet 
were in direct contact with the hot metal. 

In another case, that of a lady whose lower limbs were 
paralyzed, artificial heat was applied during the night to her 
feet. Frequently her dreams had reference to this circum- 
stance. On one occasion she dreamed that she was trans- 
formed into a bear, and was being taught to dance by being 
made to stand on hot plates of iron. On another, that the 
house was on fire, and that the floors were so hot as to burn 
her feet in her efforts to escape. Again, that she was wading 
through a stream of water which came from a hot spring in 
the Central Park. 

Another patient, a lady, subject to neuralgic attacks of 
great severity, frequently had the lancinating pains give rise 
to dreams in which she was stabbed with daggers, cut with 
knives, torn with pincers, etc. 

Not long since I had an attack of erysipelas in which the 
disease included the head and face. The pain was not severe, 
and yet it was sufficient to give rise to the following dream : 

I dreamed that I was taking a cold bath, and that while 
thus engaged a Turk, armed with a pair of long pincers, came 
into the room and began to pull the hair out of my head. I 
remonstrated, but was unable to offer any material resistance, 
for the reason that the water in which I was lying suddenly 
froze, leaving me embedded in a solid cake of ice. In order to 
facilitate his operations, the Turk sponged my head with boil- 
ing water, and then, finding the use of the pincers rather slow 
work, shaved the hair off with a red-hot razor. He then 
rubbed an ointment on the naked scalp, composed of sulphur, 
phosphorus, and turpentine, to which he immediately ap- 
plied fire. Taking me in his arms, he rushed down stairs into 
the street, lighting his way with the flame from my burning 
head. He had not gone far before he fell down in a fit, and 
in his struggles gave me a severe blow between the eyes 
which instantly deprived me of sight. 

When I awoke in the morning I had a very distinct recol- 



228 SLEEP. 

lection of this dream. The incidents were in part due to the 
fact that I had, two or three days previously, been reading an 
account of the insanity of Mohammed, and of his being sub- 
ject to attacks of epilepsy. 

The sense of taste is not, for obvious reasons, so produc- 
tive of dreams as the other senses, but the experiments of M. 
Maury and myself, to which fuller reference will presently 
be made, show that strong excitations made upon it are trans- 
mitted to the brain ; and the following instance, which has 
recently come under my immediate observation, is an inter- 
esting case in point. 

A young lady had, in her early childhood, contracted the 
habit of going to sleep with her thumb in her mouth. She 
had tried for several years to break herself of the practice, 
but all her attempts were in vain, for even when by strong 
mental effort she succeeded in getting to sleep without the 
usual accompaniment, it was not long before the unruly mem- 
ber was in its accustomed place. Finally she hit upon the 
plan of covering the offending thumb with extract of aloes 
just before she went to bed, hoping that if she put it into 
her mouth she would instantly awake. But she slept on 
through the night, and in the morning found her thumb in 
her mouth and all the extract of aloes sucked off. During the 
night, however, she dreamed that she was crossing the ocean 
in a steamer made of wormwood, and that the vessel was 
furnished throughout with the same material. The plates, 
the dishes, tumblers, chairs, tables, etc., were all of worm- 
wood, and the emanations so pervaded all parts of the ship 
that it was impossible to breathe without tasting the bitter- 
ness. Everything that she ate or drank was likewise, from 
being in contact with wormwood, so impregnated with the 
flavor that the taste was overpowering. When she arrived 
at Havre, she asked for a glass of water for the purpose of 
washing the taste from her mouth, but they brought her an 
infusion of wormwood, which she gulped down because she 
was thirsty, though the sight of it excited nausea. She went 
to Paris and consulted a famous physician, M. Sauve Moi, 
begging him to do something which would extract the worm- 
wood from her body. He told her there was but one rem- 
edy, and that was ox-gall. This he gave her by the pound, 
and in a few weeks the wormwood was all gone, but the ox- 
gall had taken its place, and was fully as bitter and disagree- 



THE PHYSIOLOGY OF DREAMS. 229 

able. To get rid of the ox-gall she was advised to take coun- 
sel of the Pope. She accordingly went to Rome, and obtained 
an audience of the Holy Father. He told her that she must 
make a pilgrimage to the plain where the pillar of salt stood, 
into which Lot's wife was transformed, and must eat a piece of 
the salt as big as her thumb. During her journey in search 
of the pillar of salt she endured a great many sufferings, but 
finally triumphed over all obstacles, and reached the object 
of her journey. What part to take was now the question. 
After a good deal of deliberation she reasoned that, as she had 
a bad habit of sucking her thumb, it would be very philo- 
sophical to break off this part from the statue, and thus not 
only get cured of the bitterness in her mouth, but also of her 
failing. She did so, put the piece of salt into her mouth, and 
awoke to find that she was sucking her own thumb. 

It might be supposed that the brain during sleep is not 
excitable through the sense of sight. Many examples, how- 
ever, are on record of dreams being thus produced, and sev- 
eral very interesting cases have come under my own observa- 
tion. Among them are the following : 

A gentleman of a nervous and irritable disposition in- 
formed me that he had dreamed of being in heaven and being 
dazzled by the brilliancy of everything around him. So great 
was the light that he hastened to escape from the pain which 
it caused in his eyes. In the efforts which he made he struck 
his head against the bedpost, and awoke to find that the fire 
which he had left smouldering on the hearth had kindled 
into a bright flame, the light from which fell full in his face. 

Another, who had been under my care for epilepsy, 
dreamed that his room was entered by burglars, and that, with 
lighted candles in their hands, they were searching his drawers 
and trunks. He related his dream the following morning, 
and was told by his mother that she had gone into his room 
the previous night, and had held a lighted candle close to his 
face in order to see whether or not he was sound asleep. 

~No one has more philosophically studied the mode of pro- 
duction of dreams than M. Maury l in his remarkable work to 
which reference has already been made. I propose, there- 
fore, to place a brief outline of his experiments and views 
before the reader. 

1 "Le sommeil et les reves; Etudes psychologiques," etc., troisieme Edition, 
Paris, 1865. 



230 SLEEP. 

Just before falling asleep, and immediately before be- 
coming fully awake, many persons are subject to hallucina- 
tions partaking of many of the characteristics belonging to 
dreams. To them the name of hypnagogic (yirvos, sleep, and 
aycoyevs, leader) hallucinations has been given — L e., halluci- 
tions which lead to sleep. Previous toM. Maury's inves- 
tigations, the phenomena in question had attracted some 
attention from German and French physiologists, but M. 
Maury's investigations, many of which were performed upon 
himself, throw more light upon the subject than it has 
hitherto received. 

According to M. Maury, the persons who most frequently 
experience these hypnagogic hallucinations are those who are 
of an excitable constitution, and are generally predisposed to 
hypertrophy of the heart, pericarditis, and cerebral affections. 
This may be true, but in two most remarkable instances 
which have come under my observation the type of organiza- 
tion was the very reverse of this. 

In M. Maury's own case, he finds that the hallucinations 
are more numerous and more vivid when he experiences, as is 
frequent with him, a disposition to cerebral congestion. Thus, 
when he has headache, nervous pains in the eyes, the ears, 
and the nose, and vertigo, the hallucinations make their ap- 
pearance as soon as he closes his eyelids. Loss of sleep and 
severe intellectual exertions invariably produce them, as do 
also cafe noir and champagne, which, by causing headache 
and insomnia, strongly predispose him to the hypnagogic 
hallucinations. On the contrary, calmness of mind, rest, and 
country air lessen his liability to them. From the inquiries 
made of others by M. Maury, the results of his own experi- 
ence, as well as from my own observations, I am well con- 
vinced that the hypnagogic hallucinations are directly the 
result of an increase in the amount of blood circulating 
through the brain rather than to actual congestion, as he sup- 
poses. They therefore indicate the existence of a condition 
unfavorable to sound sleep. 

The theory which M. Maury proposes in order to account 
for the existence of hypnagogic hallucinations further presup- 
poses that, as the power of the attention immediately before 
sleep begins to be diminished, and the mind cannot therefore 
voluntarily and logically arrange its thoughts, it abandons 
itself to the imagination, and that thus fancies arise and dis- 



THE PHYSIOLOGY OF DREAMS. 231 

appear unchecked by the other mental faculties. This ab- 
sence of the attention need not be of long duration, a second, 
or even a shorter period, being sufficient. Thus he lay down, 
and the attention which had been fully aroused soon became 
weakened ; images appeared, and these partially reawakened 
the attention, and the current of his thoughts was resumed, 
to be replaced again by hallucinations, and this continued till 
he was fully asleep. As an example, he states that on the 
30th of November, 1847, he was reading aloud the ' ' Yoyage 
dans la Kussie Meridionale," by M. Hommaire de Hell. He 
had just finished a line when he closed his eyes instinctively. 
In this short instant of sleep he saw hypnagogically, but with 
the rapidity of light, the figure of a man clothed in a brown 
robe, and with a hood on his head like a monk. The appear- 
ance of this image reminded him that he had shut his eyes 
and ceased reading. He immediately opened his eyelids and 
resumed his book. The interruption was practically nothing, 
for the person to whom he was reading did not perceive it. 

M. Maury gives numerous examples of these hypnagogic 
hallucinations, all tending to show that they are induced by 
a congested condition of the cerebral vessels, and that thus, 
according to the views I have set forth relative to the condi- 
tion of the brain in sleep, they are not to be regarded as pre- 
cursors of that state, but of stupor. 

In two very interesting cases of these hallucinations, which 
have come under my notice, they were brought about by any 
cause which increased the quantity of blood in the brain, or 
retarded the flow of blood from this organ. Thus, a glass of 
champagne or a few drops of laudanum would induce them, 
as also would the recumbent posture, with the head rather 
low. 

As showing how readily dreams can be excited by impres- 
sions made upon the senses, M. Maury caused a series of ex- 
periments to be performed upon himself when asleep, which 
afforded very satisfactory results, and which are interesting 
in connection with the points already discussed in the present 
chapter. 

First Experiment. — He caused himself to be tickled with 
a feather on the lips and inside of the nostrils. He dreamed 
that he was subjected to a horrible punishment. A mask of 
pitch was applied to his face, and then torn roughly off, tak- 
ing with it the skin of his lips, nose, and face. 



232 SLEEP. 

Second Experiment. — A pair of tweezers was held at a lit- 
tle distance from his ear, and struck with a pair of scissors. 
He dreamed that he heard the ringing of bells ; this was 
soon converted into the tocsin, and this suggested the days 
of June, 1848. 

Third Experiment. — A bottle of eau de Cologne was held 
to his nose. He dreamed that he was in a perfumer's shop. 
This excited visions of the East, and he dreamed that he was in 
Cairo in the shop of Jean Marie Farina. Many surprising adven- 
tures occurred to him there, the details of which were forgotten. 

Fourth Experiment. — A burning lucifer match was held 
close to his nostrils. He dreamed that he was at sea (the 
wind was blowing in through the windows), and that the 
magazine of the vessel blew up. 

Fifth Experiment. — He was slightly pinched on the nape 
of the neck. He dreamed that a blister was applied, and this 
recalled the recollection of a physican who had treated him 
in his infancy. 

Sixth Experiment. — A piece of red-hot iron was held close 
enough to him to communicate a slight sensation of heat. He 
dreamed that robbers had got into the house, and were forc- 
ing the inmates, by putting their feet to the fire, to reveal 
where their money was. The idea of the robber suggested 
that of the Duchess d' Abrantes, who he supposed had taken 
him for her secretary, and in whose memoirs he had read 
some account of bandits. 

Seventh Experiment. — The word parafagaramus was pro- 
nounced in his ear. He understood nothing, and awoke with 
the recollection of a very vague dream. The word maman 
was next used many times. He dreamed of different subjects, 
but heard a sound like the humming of bees. Several days 
after, the experiment was repeated with the words Azor, Cas- 
tor, Leonore. On awaking, he recollected that he had heard 
the last two words, and had attributed them to one of the 
persons who had conversed with him in his dream. 

Another experiment of the same kind showed, like the 
others, that it was the sound of the word, and not the idea it 
conveyed, which was perceived by the brain. Then the words 
chandelle, haridelle, were pronounced many times in rapid 
succession in his ear. He awoke suddenly, saying to him- 
self, dest elle. It was impossible for him to recall what idea 
he had attached to this dream. 



THE PHYSIOLOGY OF DREAMS. 233 

Eighth Experiment. — A drop of water was allowed to fall 
on his forehead. He dreamed that he was in Italy, that he 
was very warm, and that he was drinking the wine of Or- 
vieto. 

Ninth Experiment. — A light, surrounded with a piece of 
red paper, was repeatedly placed before his eyes. He dreamed 
of a tempest and lightning, which suggested the remembrance 
of a storm he had encountered in the English Channel in going 
from Merlaix to Havre. 

These observations are very instructive. They show con- 
clusively that one very important class of our dreams is due 
to our bodily sensations. I have frequently performed analo- 
gous experiments on others, and had them practiced on 
myself, and have rarely failed in obtaining decided results. 
They strongly inculcate the truth of the conclusions arrived 
at in the foregoing chapter, and they serve as important data 
in enabling us to understand the division of the subject next 
to be considered. 

In regard to the immediate cause of dreams the opinions 
of authors are very diverse. The older writers ascribe them 
to the rise of vapors from the stomach, to the visitation of 
demons, and other fanciful causes. Bishop Bull 1 declares 
that he knows from his own experience that dreams are to be 
ascribed " to the ministry of those invisible instruments of 
God's providence that guide and govern our affairs and con- 
cerns, viz., the angels of God" ; and Bishop Ken held a simi- 
lar view. 

It would neither be possible nor profitable to refer at 
greater length to views which positive physiology has over- 
turned. Observation and experiment have aided us greatly 
in arriving at definite conclusions on this subject, and the in- 
stances quoted on page 159 of this treatise, even if standing 
alone uncontradicted, would go far toward guiding us in the 
right path. On page 164 I have referred to the case of a man 
who, some time after receiving a severe injury of the head by 
which a considerable portion of the skull was lost, came un- 
der my professional care. Standing by his bedside one even- 
ing, just after he had gone to sleep, I observed the scalp 
slightly rise from the chasm in which it was deeply depressed. 
I was sure he was going to awake, but he did not, and very 

1 Sermon on the Office of the Holy Angels toward the Faithful, quoted hy 
Seafield, op. cit., vol. i, p. 157. 



234: SLEEP. 

soon lie became restless and agitated, while continuing to 
sleep. Presently he began to talk, and it was evident that 
he was dreaming. In a few minutes the scalp sank down to 
its ordinary level when he was asleep, and he became quiet. 
I called his wife's attention to the circumstance, and desired 
her to observe this condition thereafter when he slept. She 
subsequently informed me that she could always tell when he 
was dreaming from the appearance of the" scalp. 

My opinion, therefore, is that dreams are directly caused 
by an increased activity of the cerebral circulation over that 
which exists in profound sleep. This activity is probably 
sometimes local and at others general, and never equals that 
which prevails in the condition of wakefulness, when the 
functions of the brain are at their maximum of energy. This 
view is further supported by a consideration of the state of 
the brain in sleep and wakefulness, the condition of dream- 
ing being, in a measure, an intermediate one. Illustrations 
of the effects produced by a notable increase in the quantity 
of blood circulating through the brain will be given in the 
chapter on illusions and hallucinations. All of these, it will 
be perceived, have a direct bearing on the question now under 
consideration. 



CHAPTER VI. 

MORBID DREAMS. 

Moebid or pathological dreams are divided by Macario 1 
into three classes: the prodromic, or those which precede 
diseases ; the symptomatic, or those which occur in the course 
of diseases ; and the essential, or those which constitute the 
main features of diseases. As this classification is natural 
and simple, I propose to follow it in the remarks I shall have 
to make on the subject. 

Prodromic Dreams. — There appears to be no doubt that 
diseases are sometimes preceded by dreams which indicate, 
with more or less exactitude, the character of the approaching 
morbid condition. Many instances of the kind which have 
been reported — especially by the earlier authors — are, how- 
ever, in all probability, merely coincidences ; and in others 

1 Op. cit., p. 86. 



MORBID DREAMS. 235 

the relation between the character of the dream and that of 
the disease is by no means clear. 

Many cases of dreams indicating the nature of a malady 
which had not yet developed itself are referred to by Macario. 1 
The instance of Galen's patient, who dreamed that his leg 
had become converted into stone, and who was soon after- 
ward paralyzed in that member, has already been cited. 

The learned Conrad Gesner dreamed that he was bitten in 
the left side by a venomous serpent. In a short time a severe 
carbuncle appeared on the identical spot, and death ensued 
in live days. 

M. Teste, formerly minister of justice and then of public 
works under Louis Philippe, and who finally died in the Con- 
ciergerie, dreamed three days before his death that he had 
had an attack of apoplexy. Three days afterward he died 
suddenly of that disease. 

A young woman saw in a dream objects apparently con- 
fused and dim, as through a thin cloud, and was immediately 
thereafter attacked with amblyopia, and threatened with loss 
of sight. 

A woman, who had been nnder the care of M. Macario, 
dreamed, at about the period of her menstrual flow, that she 
spoke to a man who could not answer her, for the reason that 
he was dumb. On awaking, she discovered that she had lost 
her voice. 

Macario himself dreamed one night that he had a severe 
pain in his throat. On awaking, he felt very well ; but a few 
hours subsequently was attacked with severe tonsillitis. 

Arnold, of Villanova, dreamed that a black cat bit him 
in the side. The next day a carbuncle appeared on the part 
bitten. 

Dr. Forbes Winslow 3 gives several similar instances. A 
patient had, for several weeks before an attack of apoplexy, 
a series of frightful dreams, in one of which he imagined he 
was being scalped by Indians. Others dreamt of falling down 
precipices, and of being torn to pieces by wild beasts. One 
gentleman dreamed that his house was in flames, and that he 
was gradually being consumed to a cinder. This occurred a 
few days before an attack of inflammation of the brain. A 

1 Op. cit., p. 88, et seq. 

2 " On Obscure Diseases of the Brain and Disorders of the Mind," etc., 
London, 1860, p. 611, et seq. 



236 SLEEP. 

person, prior to an attack of epilepsy, dreamt that he was 
severely lacerated by a tiger ; and another, just before a seiz- 
ure, dreamt that he was attacked by murderers, and that 
they were knocking out his brains with a hammer. 

A barrister, for several years before an attack of cerebral 
paralysis, was in the habit of awaking from sleep in a condi- 
tion of great alarm and terror without being able to explain 
the reason for his apprehension. Dr. Beddoes attended a 
patient whose first fit succeeded a dream of being crushed by 
an avalanche. 

Gratiolet ' cites additional examples. Thus, Roger d'Ox- 
teryn, Knight of the Company of Douglas, went to bed in 
good health. Toward the middle of the night he saw in a 
dream a man affected with the plague and entirely naked, 
who attacked him with fury, threw him to the ground after a 
severe contest, and, holding him between his thighs, vomited 
into his mouth. Three days afterward he was seized with the 
plague and died. He also alludes to a case detailed by Gun- 
ther, in which a woman dreamt that she was being flogged 
with a whip, and, on awaking, found that she had marks on 
her body resembling the scars made by the lash. 

The existence of diseases of the heart and larger vessels is 
often revealed by frightful dreams when there is no other evi- 
dence of their presence. Macario states that a young lady 
was under his care in whom violent palpitations of the heart 
were preceded by painful dreams. She subsequently died of 
disease of the heart. 

Moreau (de la Sarthe), 3 in a very elaborate treatise on 
dreams, relates the case of a French nobleman, whom he had 
attended during several months for threatened chronic peri- 
carditis, and who was at first tormented every night by pain- 
ful and frightful dreams. These dreams, attracting attention, 
gave the earliest indication of the real condition, and excited 
fears as to the result, which were soon verified. 

He cites another case in illustration of the fact that pe- 
riodical haemorrhages are sometimes preceded by morbid 
dreams. A physician had, in his youth, been subject to peri- 
odical haemorrhages, but without dreams or other trouble 
during sleep. As he advanced in years the haemorrhages 

1 " Anatomie compare du systeme nerveux," etc. Par MM. Leuret et Gra- 
tiolet, Paris, 1839-'57, t. ii, 517, et seq. 

2 Art. " Reves," in " Grand dictionnaire de m6decine." 



MORBID DREAMS. 237 

were not so frequent, but were always preceded by a condi- 
tion of general irritation, characterized during wakefulness 
by heat of skin and frequency of the pulse, and during sleep 
by painful dreams. These dreams almost always related to 
violent actions, such as giving and receiving heavy blows, 
walking on a volcano, or being precipitated into lakes of fire. 

Many cases of insanity being preceded by frightful 
dreams are on record. Falret, 1 in calling attention to the 
remarkable analogy which exists between mental alienation 
and dreams, says that it is an incontestable fact that insanity 
is often preceded by significant dreams, and that these consti- 
tute the whole essence of the disorder by becoming firmly 
fixed in the patient's mind. Thus, he relates that Odier, of 
Geneva, was consulted, in 1778, by a lady, who, during the 
night j)receding the outbreak of her insanity, dreamed that 
her step-mother approached her with a dagger in order to kill 
her. This dream made so strong an impression upon her that 
she ultimately accredited it as true, and thus became the vic- 
tim of a delusion which rendered her a lunatic. He declares 
that numerous similar instances have come under his observa- 
tion, and refers to the case of a young lady, subject to peri- 
odical attacks of mental derangement, whose paroxysms are 
always preceded by notable dreams. 

Morel 2 affirms that many patients, before becoming com- 
pletely insane, have frightful dreams, which they regard as 
evidences that they are about to lose their reason. Some- 
times they are afraid to go to sleep on account of the terrify- 
ing apparitions which then visit them. 

The following cases, related by Dr. Forbes Winslow, 3 are 
interesting in this connection : 

"A gentleman, who had previously manifested no ap- 
preciable symptoms of mental disorder, or even of disturbed 
and anxious thought, retired to bed apparently in a sane state 
of mind. Upon arising in the morning, to the intense terror of 
his wife, he was found to have lost his senses ! He exhibited 
his insanity by asserting that he was going to be tried for an 
offence which he could not clearly define, and of the nature 
of which he had no right conception. He declared that the 

1 "Des maladies mentales et des asiles d'alienes," etc., Paris, 1864, p. 221. 

2 "Traite des maladies mentales," Paris, 1860, p. 457. 

3 " On Obscure Diseases of the Brain and Disorders of the Mind," etc., Lon- 
don, 1860, p. 614. 



238 SLEEP. 

officers of justice were in hot pursuit of him — in fact, he main- 
tained that they were actually in the house. He begged and 
implored his wife to protect him. He walked about the bed- 
room in a state of great agitation, apprehension, and alarm, 
stamping his feet, and wringing his hands in the wildest agony 
of despair. Upon inquiring into the history of the case, his 
wife said that she had not observed any symptoms that ex- 
cited her suspicions as to the state of her husband's mind, but, 
upon being questioned very closely, she admitted that during 
the previous night he appeared to have been under the influ- 
ence of what she considered to be the nightmare, or a frigthf ul 
dream. While apparently asleep he cried out several times, 
evidently in great distress of mind, ' Don't come near me ! ' 
' Take them away ! ' * Oh, save me ; they are pursuing me ! ' 
It is singular that in this case the insanity which was clearly 
manifested in the morning appeared like a continuation of 
the same character and train of perturbed thought that ex- 
isted during his troubled sleep, when, according to the wife's 
account, he was evidently dreaming." 

Dr. Winslow's second case is equally to the point : "I am 
indebted to a medical friend for the particulars of the follow- 
ing case. During the winter of 1849 he was called to see 
H. B., about five or six o'clock in the morning. The patient 
was the wife of a tailor, and mother of three children. At 
this time she was rather emaciated and debilitated in bodily 
health, and anaemic in appearance. She was of a religious 
turn of mind, and belonged to the Wesleyan persuasion. On 
the morning of the narrator's visit, he found the woman in a 
state of great mental excitement, and under the influence of 
hallucinations. She had gone to bed apparently well, but 
during the night was the subject of a vivid dream, imagining 
that she saw her sister, long since dead and to whom she was 
much attached, suffering the pains of hell. When quite 
awake, no one could persuade her that she had been under 
the influence of an agitated dream. She stoutly persisted in 
maintaining the reality of her vision. During the whole of 
that day she was clearly insane, but on the following morn- 
ing her mind appeared to have recovered its balance. She 
continued tolerably well, mentally, for four years, with the 
exception of her occasionally having moments of despond- 
ency, arising from real or fancied troubles." . . . 

The further particulars of this case, relating as they do to 



MORBID DREAMS. 239 

another division of the subject — " sleep-drunkenness," as the 
Germans designate it — will be considered under that head. 

Without pretending to endorse all the conclusions of 
Albers — as set forth in the following summary, and which I 
quote from a very learned and philosophical writer 1 — there is 
no doubt that some of his dicta are well founded. 

"lively dreams are in general a sign of the excitement of 
nervous action. 

" Soft dreams are a sign of slight irritation of the head ; 
often in nervous fevers announcing the approach of a favor- 
able crisis. 

" Frightful dreams are a sign of determination of blood to 
the head. 

" Dreams about fire are, in women, signs of an impending 
haemorrhage. 

" Dreams about blood and red objects are signs of inflam- 
matory conditions. 

"Dreams about rain and water are often signs of diseased 
mucous membranes and dropsy. 

"Dreams of distorted forms are frequently a sign of ab- 
dominal obstructions and diseases of the liver. 

"Dreams in which the patient sees any part of the body 
especially suffering, indicate disease in that part. 

"Dreams about death often precede apoplexy, which is 
connected with determination of blood to the head. 

"The nightmare (incubus ephialtes), with great sensitive- 
ness, is a sign of determination of blood to the chest." 

A very interesting paper on dreaming, by Dr. Thomas 
More Madden, 8 has been recently published, and from it I 
make the following extract : 

"Intermittent fever is often announced, several days be- 
fore any of the recognized symptoms set in, by persistent 
dreams of terrifying character. I have experienced this in 
my own person, and heard it confirmed by other sufferers 
on the African coast. The following case of morbid dream- 
ing, ushering in yellow fever, I subjoin in the words of the 
gentleman to whom it occurred, himself a medical man hold- 

1 " The Principles of Medical Psychology." Being the Outlines of a Course 
of Lectures by Baron Ernst von Feuchtersleben, M. D. Sydenham Society 
Translation, p. 198. 

2 Medical Press and Circular ; also, Quarterly Journal of Psychological 
Medicine and Medical Jurisprudence, vol. i, p. 276. 



2i0 . SLEEP. 

ing a high official position on the Gold Coast, where it oc- 
curred. 

" ' In the early part of 1840 I was an inmate of Cape Coast 
Castle, and, as some repairs were then being made in the 
castle, the room assigned to me was that in which the ill-fated 
L. E. L. (Mrs. Maclean), the wife of the governor of Cape 
Coast, had been fonnd dead, poisoned by prnssic acid, not 
very long previously. I had known her in London, and had 
been intimately acquainted with her history and much inter- 
ested in it. Her body had been found on the floor near the 
door and in front of a window. After a fatiguing excursion 
to some of the adjoining British settlements on the coast, 
having retired to rest, I awoke, disturbed by a dream of a 
very vivid character, in which I imagined that I saw the dead 
body of the lady, who had died in that chamber, lying on the 
floor before me. On awaking, the image of the corpse kept 
possession of my imagination. The moon was shining 
brightly into the part of the room where the body had been 
found, and there, as it seemed to me on awaking, it lay, pale 
and lifeless, as it appeared to me in my dream. 

" ' After some minutes I started up, determined to ap- 
proach the spot where the body seemed to be. I did so, not 
without terror, and, walking over the very spot on which the 
moon was shining, the fact all at once became evident and 
obvious that no body was there — that I must have been 
dreaming of one. I returned to bed, and had not long fallen 
asleep when the same vivid dream recurred ; the same waking 
disturbance occurring while awake. As long as I lay gazing 
on the floor I could not dispossess my mind of that appalling 
vision ; but, when I started up and stood erect, it vanished at 
the first glance. 

" 'Again I returned to bed, dozed, dreamt again of poor 
L. E. L.'s lamentable end, and of her remains in the same 
spot ; again awoke, and arose with the same strange results. 

" 'There was no more disturbance that night of which, at 
least, I was conscious, but when morning came fever was on 
me in unmistakable force in its worst form, and partial delir- 
ium set in the same night. I was reduced to the last extrem- 
ity about the third or fourth night of my illness, when a con- 
viction seized on my mind that it was absolutely essential to 
my life that I should not pass another night in Cape Coast 
Castle. I caused the negro servant I had fortunately brought 



MORBID DREAMS. 241 

out with me from England to have a litter prepared for me at 
dawn, and, stretched on this litter, hardly able to lift hand or 
foot, I was carried out of my bed by four native soldiers, and 
was conveyed to the house of a merchant, and countryman of 
mine, to whose care and kindness I owe my life. So much 
for a visionary precursor of fever on the west coast of Africa.' 

" In neuralgia, disturbed dreaming is occasionally a promi- 
nent symptom. In an obscure case I was led to make what I 
believe to be a true diagnosis from the indications furnished 
by the patient's dreams. The individual in question is a man, 
aged about forty -five, of an anaemic habit, confined by a sed- 
entary occupation, who, for many years, had suffered from 
hemicrania, which lately had become more intense, and the 
intervals shorter. A couple of days before the attack his 
sleep becomes broken by unpleasant dreams, and, when the 
paroxysm has attained its height, he invariably dreams 
that he is the helpless victim of a persecutor, who finishes a 
series of torments by driving a stake through his skull. Dur- 
ing his recovery from each attack he states that his dreams 
are of a most agreeable character, though so vague that he 
cannot give any account of them. The frequent repetition of 
his dreams leads me to conclude that there is some osseous 
growth within the cranium, and that the vascular distention 
accompanying the neuralgic attack occasions pressure upon 
this, giving rise to the sensation I have referred to, while the 
subsequent feeling of comfort results from that pressure be- 
ing removed." 

A case has been recently published ' in which the dream 
immediately preceded, or perhaps even accompanied, the 
morbid action. A German, aged forty-five, of a nervo-san- 
guineous temperament, went to bed at 11 p. m., feeling as well 
as usual. Between 12 and 1 o' clock he dreamed that he saw 
his child lying at his side, dead. He was very much fright- 
ened, and at once awoke, to find that his tongue was para- 
lyzed, and that he could not talk. The faculty of speech and 
the ability to move the tongue remained impaired for four 
months. 

For several years past I have made inquiries of patients 
and others relative to their dreams, and have thus collected a 
large amount of material bearing upon the subject. With 

1 Medical Investigator ; also, Quarterly Journal of Psychological Medicine^ 
etc., April, 1868, p. 405. 
16 



212 SLEEP. 

reference to the point under consideration, the data in my 
possession are exceedingly important and interesting. Among 
the cases which have come under my observation of diseases 
being preceded by morbid dreams are the following : 

A gentleman, two days before an attack of hemiplegia, 
dreamed that he was cut in two exactly down the mesial line, 
from the chin to the perinseum. By some means, union of the 
divided surfaces was obtained, but he could only move one 
side. On awaking, a little numbness existed in the side 
which he had dreamed was paralyzed. This soon passed off, 
and ceased to engage his attention. The following night he 
had a somewhat similar dream, and the next day, toward 
evening, was seized with the attack which rendered him hemi- 
plegic. 

Another dreamed one night that a man dressed in black and 
wearing a black mask came to him and struck him violently 
on the leg. He experienced no pain, however, and the man 
continued to beat him. In the morning he felt nothing, with 
the exception of a slight headache. Nothing unusual was 
observed about the leg, and all went on well, until on the 
fifth day he had an apoplectic attack, accompanied with 
hemiplegia, including the leg which he had in his dream im- 
agined to have been struck. 

A lady, aged forty, who had been a great sufferer from 
rheumatism for many years, dreamt one afternoon, while sit- 
ting in her chair in front of the fire, that a boy threw a stone 
at her, which, striking her on the face, inflicted a very severe 
injury. The next day violent inflammation of the tissues 
around the facial nerve as it emerges from the stylo-mastoid 
foramen set in, and paralysis of the nerve followed, due to 
effusion of serum, thickening, and consequent pressure. 

A young lady dreamt that she was seized by robbers and 
compelled to swallow melted lead. In the morning she felt 
as well as usual, but toward the middle of the day was at- 
tacked with severe tonsillitis. 

A young man informed me that, a day or two before be- 
ing attacked with acute meningitis, he had dreamed that he 
was seized by banditti while travelling in Spain, and that they 
had taken his hair out by the roots, causing him great pain. 

A lady of decided good sense had an epileptic seizure, 
which was preceded by a singular dream. She had gone to 
bed feeling somewhat fatigued with the labors of the day, 



MORBID DREAMS. 243 

which had consisted in attending three or four morning recep- 
tions, winding np with a dinner party. She had scarcely- 
fallen asleep when she dreamed that an old man, clothed in 
black, approached her, holding an iron crown of great weight 
in his hands. As he came nearer, she perceived that it was 
her father, who had been dead several years, but whose feat- 
ures she distinctly recollected. Holding the crown at arm's 
length, he said: "My daughter, during my lifetime I was 
forced to wear this crown ; death relieved me of the burden, 
but it now descends to you." Saying which, he placed the 
crown on her head and disappeared gradually from her sight. 
Immediately she felt a great weight and an intense feeling of 
constriction in her head. To add to her distress, she imag- 
ined that the rim of the crown was studded on the inside with 
sharp points which wounded her forehead, so that the blood 
streamed down her face. She awoke with agitation, excited, 
but felt nothing uncomfortable. Looking at the clock on 
the mantel-piece, she found that she had been in bed ex- 
actly thirty -five minutes. She returned to bed, and soon fell 
asleep, but was again awakened by a similar dream. This 
time the apparition reproached her for not being willing to 
wear the crown. She had been in bed this last time over 
three hours before awaking. Again she fell asleep, and again, 
at broad daylight, she was awakened by a like dream. 

She now got up, took a bath, and proceeded to dress her- 
self with her maid's assistance. Recalling the particulars of 
her dream, she recollected that she had heard her father say 
one day that in his youth, while being in England, his na- 
tive country, he had been subject to epileptic convulsions con- 
sequent on a fall from a tree, and that he had been cured by 
having the operation of trephining performed by a distin- 
guished London surgeon. 

Though by no means superstitious, the dreams made a 
deep impression upon her, and, her sister entering the room 
at the time, she proceeded to detail them to her. While thus 
engaged, she suddenly gave a loud scream, became uncon- 
scious, and fell upon the floor in a true epileptic convulsion. 
This paroxysm was not a very severe one. It was followed in 
about a week by another ; and, strange to say, this was pre- 
ceded, as the other, by a dream of her father placing an iron 
crown on her head, and of pain being thereby produced. 
Since then several months have elapsed, and she has had no 



244 SLEEP. 

other attack, owing to the influence of the bromide of potas- 
sium, which she continues to take. 

In the case of a gentleman now under my treatment for 
epilepsy, the fits are invariably preceded by dreams of diffi- 
culties of the head, such as decapitation, hanging, perforation 
with an auger, etc. 

A lady, previous to an attack of sciatica, dreamed that she 
had caught her foot in a spring- trap, and that before she 
could be freed it was necessary to amputate the member. 
The operation was performed; but, as she was released, a 
large dog sprang at her and fastened his teeth in her thigh. 
She screamed aloud, and awoke in her terror. Nothing un- 
usual was perceived about the leg ; but, on getting up in the 
morning, there was slight pain along the course of the sciatic 
nerve, and this before evening was developed into well-marked 
sciatica. 

Insanity is frequently preceded by frightful dreams, and I 
have advanced several examples to this effect from the expe- 
rience of others. We should naturally expect that very often 
the first manifestations of a diseased brain should appear 
during sleep. But dreams are of such a varied character, and 
so thoroughly irreconcilable with the normal mental phenom- 
ena of the wakeful state, that it is difficult to say that such 
or such a dream is evidence of a diseased mind. As, in some 
of the cases I have brought forward, a dream may take so firm 
a hold of the reason as to be the exciting cause of insanity, 
and not simply a sign of its approach, I am disposed, from 
my own experience, to regard the frequent repetition of the 
same dream as often indicative of a disordered mind, when 
very close observation would fail to reveal other evidences. 
There are, however, exceptions to this statement, as has been 
shown in the previous chapter. 

Several cases, in which insanity was preceded by terrify- 
ing dreams, have come under my observation. In one of 
them a lady dreamed that she had committed murder, under 
circumstances of great atrocity. She cut up the dead body, 
but could not, with all her efforts, divide the head, which re- 
sisted the blows, with an axe and other instruments. Finally 
she filled the nose, eyes, and mouth with gunpowder, and 
applied a match. Instead of exploding, smoke issued slowly 
from the orfices of the skull, and was resolved into a human 
form, which turned out to be that of a police officer sent to 



MORBID DREAMS. 245 

arrest her. She was imprisoned, tried, and sentenced to exe- 
cution, by being drowned in a lake of melted sulphur. While 
the preparations were being made for the punishment she 
awoke. She related the particulars of her dream to several 
friends, but it apparently made no great impression on her 
mind. The next night she dreamed of somewhat similar cir- 
cumstances, and for several nights subsequently. On the 
sixth day, without any premonition, she attempted to kill 
herself by plunging a pair of scissors into her throat, and 
since that time to her death, which took place a few months 
subsequently, was constantly insane. 

In this case there was no direct analogy between the char- 
acter of her dream and the type of insanity which ensued. 
It cannot, therefore, be said that the dream produced the 
mental aberration. On the contrary, the dream was, in all 
probability, the first evidence of deranged cerebral action, a 
condition which subsequently became developed into positive 
insanity. 

The following case is similar to the foregoing in its general 
features : 

A gentleman, who had been unfortunate in some business 
speculations, shortly afterward became insane. Previous to 
this event he was troubled with frightful dreams, which gave 
him a great deal of annoyance, and frequently caused him to 
awake in terror. One of them occurred several times, and 
was of the following character ; He dreamed that he was en- 
gaged to be married to a lady of beauty and wealth, and who 
was, moreover, possessed of great musical talent. One even- 
ing, as he in his dream was paying her a visit, she placed 
herself at the piano and began to sing. He remarked that he 
did not admire the piece of music she was singing, and asked 
her to sing something else. She indignantly refused. Angry 
words followed, and in the midst of the dispute she drew a 
dagger from her bosom and stabbed herself to the heart. As 
he rushed forward, horror-struck, to her assistance, her 
friends entered the room, and found him with the dagger in 
his hand. He was accused of murdering the lady, and, not- 
withstanding his protestations of innocence, was tried, found 
guilty, and sentenced to be hanged. He always awoke at the 
point when preparations were being made for his execution. 

A dream may make such a strong impression on the mind 
as to subsequently constitute the essential feature of the in- 



216 SLEEP. 

sane condition. This point lias already been elucidated to 
some extent in the preceding pages. The following cases, 
however, are from my own records of practice : 

A gentleman awoke in the middle of the night, and, call- 
ing his wife, told her he had dreamed that a large fortune 
had been left him by a miner in California. He then went to 
sleep again, but in the morning again repeated the dream to 
his wife, and said that " there might be something in it." She 
laughed, and remarked that she ' ' hoped it might prove true." 
About the time the California steamer was expected, the gen- 
tleman was observed to become very anxious and excited, and 
was continually talking of his expected fortune. At last the 
steamer arrived. He then began asking the postman for let- 
ters from California, went several times a day to the post- 
office to make like inquiries, and finally went aboard the 
steamer and questioned the officers on the same subject. 
Then he was sure the letter had miscarried, and would sit 
for hours in the most profound melancholy. He was now 
recognized by his family as a monomaniac, and strenuous 
efforts were made to cure him of his delusion, but they were 
unsuccessful ; and, although now apparently sane on other 
subjects, he still holds the erroneous idea which was first 
given him in his dream of several years ago. 

A young lady was brought to me in July, 1868, who had 
been rendered insane by a dream which took place a few 
months before I saw her. She went to bed one night in good 
health and spirits, though somewhat fatigued in consequence 
of having skated a good deal the previous afternoon. In the 
morning she told her mother she had committed the " unpar- 
donable sin," and that there was consequently no hope of her 
salvation. She based her idea on a dream she had had, in 
which an angel appeared to her, and sorrowfully informed 
her of her sin and her destiny. When asked to tell what her 
sin was, she refused to do so, saying it was too shocking and 
atrocious to talk about. She kept to her delusion, and soon 
settled into a sort of melancholic stupor, from which it was 
impossible entirely to rouse her. Under the use of arsenic 
and the acid phosphate of lime she gradually recovered her 
reason. 

The manner in which prodromic dreams are excited is very 
simple. The ancients and some modern writers have regarded 
them as prophetic ; but the true explanation does not require 



MORBID DREAMS. 247 

so severe a tax on our powers of belief. In the previous 
chapter, it was shown that very slight impressions made upon 
the senses during sleep are exaggerated by the partially awak- 
ened brain. The first evidence of approaching paralysis may 
be a very minute degree of numbness — so minute that the 
brain, when awake and engaged with the busy thoughts of 
active life, fails to appreciate it. During sleep, however, the 
brain is quiescent, till some exciting cause sets it in uncon- 
trollable action, and dreaming results. Such a cause may be 
the incipient numbness of a limb. A dream of its being 
turned into stone, or cut off, or violently struck, is the conse- 
quence. The disease goes on developing, and soon makes its 
presence unmistakable. 

This explanation applies mutatis mutandis to all pro- 
dromic dreams. They are invariably based upon actual sen- 
sations, unless we except the rare cases which are simply co- 
incidences. 

Symptomatic Dreams. — Morbid dreams are so generally 
met with in the course of disease, especially in that of the 
brain and nervous system, that I never examine a patient 
without questioning him closely on this point. The in- 
formation thus obtained is always valuable, and sometimes 
constitutes the most important feature of the investiga- 
tion. 

Fevers are very often accompanied by frightful dreams. 
According to Moreau (de la Sarthe), 1 their occurrence indi- 
cates that the attack will be long, and that there is probably 
some organic affection present. My own experience agrees 
with that of Macario, 2 to the effect of not confirming these 
opinions. I have, however, generally observed that the fre- 
quency and intensity of the morbid dreams were in proportion 
to the severity of the fever. 

Diseases of the heart are very generally attended with 
disagreeable dreams. They are usually short, and, as Ma- 
cario remarks, relate to approaching death. The patient 
starts from sleep in terror, and sometimes it is difficult to 
convince him of the unreality of his visions. 

Dyspepsia and other diseases of the intestinal canal 
often give rise to morbid dreams. They are usually accom- 
panied by a sense of impending suffocation, and ordinarily 
consist of frightful images, such as devils, demons, strange 

1 Op. cit. } art. "R6ves." 2 Op. cit., p. 95. 



218 SLEEP. 

animals, and the like. The presence of worms in the intes- 
tines is likewise a frequent cause of such dreams. 

In chlorosis, dreams are very common. Occasionally they 
are of a pleasant character, but in the majority of cases they 
are the reverse of this. 

It would be difficult to mention a disease which is not, at 
some time or other of its career, an exciting cause of morbid 
dreams. The most interesting examples, however, are met 
with in cases of insanity and other cerebral affections, and 
frequently the delusions of the dreams are so mixed up with 
those which arise during the waking condition that the pa- 
tient is unable to separate them and to determine which are 
the consequence of erroneous sensations received when 
awake, and which are the results of dreams. The careful 
examination of almost any insane persons will also show that 
they incorporate the fancies of their dreams with the realities 
of every- day life. Indeed, the relations of dreaming to insan- 
ity are so interesting and important as to have attracted the 
marked attention of alienists and psychologists. 

Cabanis l gives Cullen the credit of being the first to point 
out the similarity between the phenomena of dreaming and 
those of delirium, and himself enters at length into the full 
discussion of the several questions involved. A very little 
reflection will suffice to convince the reader that the two con- 
ditions are strikingly alike. In dreams we never distinguish 
the false from the real ; the judgment, if exercised at all, 
acts in the most erratic manner ; we are rarely surprised at 
the occurrence of the most improbable circumstances ; our 
characters for the time being often undergo a radical change, 
and we perform imaginary acts in our sleep which are alto- 
gether at variance with our actual dispositions. The halluci- 
nations of sleep we accept as realities just as the insane indi- 
vidual believes in all the erroneous impressions made upon his 
senses. The dreaming person is, in fact, the victim of delu- 
sions which, during the existence of his condition, have a firm 
hold on his mind, and render him in no essential particular 
different from the one who suffers from mental unsoundness. 
The incoherence present in dreams and the evident depend- 
ence of the various images upon the suggestion of previous 
images are likewise phenomena of the insane state. 

Even in persons perfectly sane, dreams often produce a 
1 " Pwapports du physique et du morale de l'homme," Paris, 1824, t. ii, p. 359. 



MORBID DREAMS. 249 

very powerful influence on the mind. Most of us have, on 
awaking, felt pleased or disturbed from reflecting upon the 
circumstances of a dream we have had during the night, and 
occasionally the impression has remained through the entire 
day. With children this influence is still more strongly 
shown. As Sir Henry Holland 1 remarks, the corrections from 
reason and experience are less complete in them than in 
adults. As a consequence, they not infrequently confuse 
their dream-visions with the facts of their lives, and regard 
the former as real events. The hallucinations of dreams are 
also occasionally continued during wakefulness, and hence 
some persons have, on awaking, seen the images which had 
been present to them in their sleep. 

The celebrated Benedict de Spinoza 2 was once the subject 
of an illusion which had its starting-point in a dream. He 
dreamed that he was visited by a tall, thin, and black Bra- 
zilian, diseased with the itch. He awoke, and thought he saw 
such an image standing beside him. 

Muller, 3 in referring to such instances, says : 
"I have myself also very frequently seen these phantasms, 
but am now less liable to them than formerly. It has become 
my custom, when I perceive such images, immediately to open 
my eyes, and direct them upon the wall or surrounding ob- 
jects. The images are then still visible, but quickly fade. 
They are seen whichever way the head is turned, but I have 
not observed that they moved with the eyes. The answers to 
the inquiries which I make every year of the students attend- 
ing my lectures, as to whether they have experienced any- 
thing of the kind, have convinced me that it is a phenomenon 
known to comparatively few persons. For, among a hundred 
students, two or three only, and sometimes only one, have ob- 

1 " Chapters on Mental Physiology," London, 1852, p. 126. 

2 B. D. S. " Opera Postliuma," 1677, Epistola xxx, p. 471. In the course of 
this letter to his friend, Peter BaDing, Spinoza says : 

" Quum quodam mane, lucesente jam cselo, ex soranio gravissima evigilarem 
imagines, quae mini in somnio occurrerant, tarn vivide oh oculos versabantur, ac 
si res finissent verae, et prsesertim cujusdam nigri et scabiosi Brasiliani, quern 
nunquam antea videram. Haec imago partem maximam disparebat, quando, ut 
me alia re oblectarem, oculus in librum, vel aliud quid defigibam ; quamprimium 
verd oculos a tali objecto rursus avertebam, sine attentione in aliquid oculos 
defigendo, mihi eadem ejnsdem ^Ethiopis imago eadem vividetate, et per vices 
apparebat, donee paulatim circa caput disparetet." 

3 "Elements of Physiology," translated by Baly, vol. ii, p, 1394. 



250 SLEEP. 

served it. This rarity of the phenomena is, however, more 
apparent than real. I am satisfied that many persons wonld 
perceive these spectres if they learned to observe their sensa- 
tions at the proper times. There are, however, undoubt- 
edly, many individuals to whom they never appear, and in my 
own case they now sometimes fail to show themselves for 
several months at a time, although in my youth they oc- 
curred frequently. Jean Paul recommended the watching of 
the phantasms which appear to the closed eyes as a means of 
inducing sleep." 

If such phenomena take place in persons of healthy brains, 
the greater liability of the insane to experience them will 
readily be admitted. 

The character of dreams, as Macario a remarks, varies ac- 
cording to the type of insanity to which the patient is sub- 
ject. In melancholia they are ordinarily sad and depressing, 
and leave a deep and lasting impression ; in expansive mono- 
mania they are gay and exciting ; in mania they give evidence 
of the extraordinary mental excitement and activity of the 
subject, and in duration they are vague, fleeting, and occur 
but seldom. 

Essential Morbid Dreams. — Under this head are com- 
prehended the various forms of frightful dreams which are 
ordinarily designated under the name of nightmare. It has 
been my good fortune to have had the opportunity of care- 
fully studying the phenomena of this singular affection in 
several persons of intelligence, and I propose, therefore, de~ 
tailing the results of my own experience, after a short his- 
torical retrospect, which I hope will not prove uninterest- 
ing. 

Nightmare is characterized by the existence during sleep 
of a condition of great uneasiness, the principal features of 
which are a sense of suffocation, a feeling of pain or of con- 
striction in some part of the body, and a dream of a painful 
character. There are thus two essential elements of the affec- 
tion — the bodily and the mental. 

At a very early period the phenomena of nightmare at- 
tracted the attention of physicians. Hippocrates 2 describes it 
in the following words : "I have often seen persons in their 
sleep utter groans and cries, appear as if suffocated, and 
throw themselves wildly about until they finally waked. 

* Op. cit., p. 93. a Uepi Uprjq voao. 



MORBID DREAMS. 251 

Then they were in their right minds, but were, nevertheless, 
pale and weak." 

The general opinion held at that time was that the phe- 
nomena of nightmare were due to excess of bile and dryness 
of the blood. This view originated with Hippocrates, but was 
more or less modified by subsequent writers. 

After the establishment of Christianity, the conviction 
began to prevail that during an attack of nightmare the sub- 
ject was visited by a demon, who, for the time being, took 
possession of his body. Oribasius, in the fourth century, 
combated this idea, and endeavored to show that it was a 
severe disease, which, if not cured, might lead to apoplexy, 
mania, or epilepsy. He located it in the head. 

Aetius also denied the existence of demoniacal agency in 
nightmare. He considered it as a prelude to epilepsy, mania, 
or paralysis. 

During the middle ages nightmare was attributed to the 
power of the devil. Imps, male and female, called incubi 
and succubi, respectively, were supposed to be the active 
agents in producing the affection. The treatment was in ac- 
cordance with the theory, and consisted of prayers and exor- 
cisms. Not unfrequently the subject of the disease perished 
at the stake for the alleged crime of having sexual intercourse 
with incubi or succubi, according to sex. 

Even in later times many persons have been found who 
believed implicitly in the reality of the visions which they 
experienced during an attack of nightmare. Thus, Jan- 
sen 'relates that a clergyman came to consult him. " Mon- 
sieur," said he, " if you do not help me I shall certainly 
go into a decline, as you see I am thin and pale — in fact, 
I am only skin and bone ; naturally I am robust, and of 
good appearance ; now I am scarcely more than the shadow 
of a man." 

" What is the matter with you ? " said Jansen. " And to 
what do you attribute your disease % " 

" I will tell you," answered the clergyman, " and you will 
assuredly be astonished at my story. Almost every night a 
woman, whose figure is not unknown to me, comes and throws 
herself on my breast, and embraces me with such power that 
I can scarcely breathe. I endeaver to cry out, but she stifles 
my voice, and the more I try, the less successful I am. I can 
1 Quoted from I. Franck by Macario, op. cit. } p. 100. 



252 SLEEP. 

neither use my arms to defend myself, nor my legs to escape. 
She holds me bound and immovable." 

"But," said the doctor, "what you relate is not in the 
least surprising. Your visitor is an imaginary being, a shade, 
a phantom, an effect of your imagination." 

" Not so ! " exclaimed the patient. M I call God to wit- 
ness that I have seen with my own eyes the being of whom I 
speak, and I have touched her with my hands. I am awake, 
and in the full possession of my faculties, when I see this 
woman before me. I feel her as she attacks me, and I try to 
contend with her, but fear, anxiety, and languor prevent me. 
I have been to every one, asking for aid to bear up against my 
horrible fate, and, among others, I have consulted an old 
woman who has the reputation of being very skilful, and 
something of a sorceress. She directed me to urinate toward 
daylight, and to immediately cover the pot de chambre with 
the boot of my right foot. She assured me that on the very 
day I would do this the woman would pay me a visit. 

"Although this seemed to me very ridiculous, and al- 
though my religion was altogether against my making any 
such experiment, I was finally induced, by reflecting on my 
sufferings, to follow the advice I had received. I did so, and, 
sure enough, and on the same day, the wicked woman who 
had so tormented me came to my apartment, complaining of 
a horrible pain in the bladder. All my entreaties and threats, 
however, were unavailing to induce her to cease her nocturnal 
visits." 

Jansen at first could not turn this gentleman from his in- 
sane idea, but, finally, after two hours' conversation, he made 
him have some just conception of the nature of his disease, 
and inspired him with the hope of a cure. 

Epidemics of nightmare have been noticed, and it likewise 
sometimes prevails endemically under certain peculiar forms. 
Thus, vampirism, a belief in which exists in different parts of 
the world, is nothing but a kind of nightmare. Charles No- 
dier ' gives some interesting details on this point, which I do 
not hesitate to transcribe. 

In Morlachia there is scarcely a hamlet which has not sev- 
eral vukodlaclcs or vampires, and there are some, every fam- 
ily of which has its vukodlaclc, just as every Alpine family 
has its cretin. The cretin, however, has a physical infirmity, 
1 " De quelques phenomenes du sommeil." (Euvres complets, t. v, p. 170-175. 



MORBID DREAMS. 253 

and with it a morbid state of the brain and nervons system, 
which destroys his reason, and prevents him appreciating his 
degraded condition. The vuTcodlack, on the contrary, appre- 
ciates all the horror of his morbid perception ; he fears and 
detests it ; he combats it with all his power ; he has recourse 
to medicine, to prayers, to division of a muscle, to the ampu- 
tation of a limb, and sometimes even to suicide. He demands 
that after his death his children shall pierce his heart with 
a spike, and fasten his corpse to the coffin, so that his dead 
body, in the sleep of death, may not be able to follow the 
instinct of the living body. The vukodlack is, moreover, 
often a man of note, often the chief of the tribe, the judge, or 
the poet. 

Through the sadness which is due to the recollection of his 
nocturnal life, the vukodlack exhibits the most generous and 
lovable traits of character. It is only during his sleep, when 
visited with his terrible dreams, that he is a monster, digging 
up the dead with his hands, feeding on their flesh, and wak- 
ing those around him with his frightful cries. 

The superstition is that during this state of morbid dream- 
ing the soul of the sleeper quits the body to visit the ceme- 
teries, and feast upon the remains of the recently dead. 

In Dalmatia the belief is current that there are sorcerers 
whose delight is to tear out the hearts of lovers, and to cook 
and eat them. Nodier relates the story of a young man 
about to be married, who was the constant victim of night- 
mare, during which he dreamed that he was surrounded by 
these sorcerers, ready to pluck his heart from his breast, but 
who often awakened just as they were about to proceed to ex- 
tremities. In order to be effectually relieved from their visi- 
tations, he was advised to avail himself of the company of an 
old priest, who had never previously heard of these horrible 
dreams, and who did not believe that God would give such 
power to the enemies of mankind. After using various forms 
of exorcism, the priest went peacefully to sleep in the same 
room with the patient whom he was commissioned to defend 
against the sorcerers. Hardly, however, had sleep descended 
upon his eyelids than he thought he saw the demons hover- 
ing over the bed of his friend, alight, and, laughing horribly, 
throw themselves on his prostrate body, and with their claws 
tear open his breast, and, seizing his heart, devour it with 
frightful avidity. Unable to move from his bed, or to utter a 



254 SLEEP. 

sound, lie was forced to witness this terrible scene. At last 
lie awoke, to see no one but his companion, pale and haggard, 
staggering toward him, and finally falling dead at his feet. 

These two men, adds Nodier, had had similar attacks. 
What the one dreamed he saw, the other dreamed he had ex- 
perienced. 

As an instance of like dreams occurring to many persons at 
the same time, the circumstances related by Laurent ' are 
worthy of notice. 

"The first battalion of the regiment of Latour d'Auvergne, 
of which I was surgeon-major, while in garrison at Palmi, in 
Calabria, received orders to march at once to Tropea in order 
to oppose the landing from a fleet which threatened that part 
of the country. It was in the month of June, and the troops 
had to march about forty miles. They started at midnight, 
and did not arrive at their destination till seven o'clock in 
the evening, resting but little on the way, and suffering much 
from the heat of the sun. When they reached Tropea, they 
found their camp ready and their quarters prepared, but as 
the battalion had come from the farthest point, and was the 
last to arrive, they were assigned the worst barracks, and 
thus eight hundred men were lodged in a place which, in 
ordinary times, would not have sufficed for half their number. 
They were crowded together on straw placed on the bare 
ground, and, being without covering, were not able to undress. 
The building in which they were placed was. an old, aban- 
doned abbey, and the inhabitants had predicted that the bat- 
talion would not be able to stay there all night in peace, as it 
was frequented by ghosts, which had disturbed other regi- 
ments quartered there. We laughed at their credulity ; but 
what was our surprise to hear, about midnight, the most 
frightful cries issuing from every corner of the abbey, and to 
see the soldiers rushing terrified from the building. I ques- 
tioned them in regard to the cause of their alarm, and all re- 
plied that the devil lived in the building ; that they had seen 
him enter by an opening into their room, under the figure of 
a very large dog, with long black hair, and, throwing himself 
upon their chests for an instant, had disappeared through 
another opening in the opposite side of the apartment. We 
laughed at their consternation, and endeavored to prove to 
them that the phenomenon was due to a very simple and natu- 

1 "Grand dictionnaire do medecine," t. xxxiv., art. "Incubi," par M. Parent. 



MORBID DREAMS. 255 

ral cause, and was only the effect of their imagination ; but 
we failed to convince them, nor could we persuade them to 
return to their barracks. They passed the night scattered 
along the sea- shore, and in various parts of the town. In the 
morning. I questioned anew the non-commissioned officers and 
some of the oldest soldiers. They assured me that they were 
not accessible to fear ; that they did not believe in dreams or 
ghosts, but that they were fully persuaded they had not been 
deceived as to the reality of the events of the preceding night. 
They said they had not fallen asleep when the dog appeared, 
that they had obtained a good view of him, and that they 
were almost suffocated when he leaped on their breasts. We 
remained all day at Tropea, and, the town being full of troops, 
we were forced to retain the same barracks, but we could not 
make the soldiers sleep in them again without our promise 
that we would pass the night with them. I went there at 
half past eleven with the commanding officer ; the other 
officers were, more for curiosity's sake than anything else, 
distributed in the several rooms. We scarcely expected to 
witness a repetition of the events of the preceding night, for 
the soldiers had gone to sleep, reassured by the presence of 
their officers, who remained awake. But about one o'clock, 
in all the rooms at the same time, the cries of the previous 
night were repeated, and again the soldiers rushed out to 
escape the suffocating embrace of the big black dog. We 
had all remained awake, watching eagerly for what might 
happen, but, as may be supposed, we had seen nothing. 

"The enemy's fleet having disappeared, we returned next 
day to Palmi. Since that event we have marched through 
the kingdom of Naples in all directions and in all seasons, 
but the phenomena have never been reproduced. We are of 
opinion that the forced march which the troops had been 
obliged to make during a very hot day, by fatiguing the 
organs of respiration, had weakened the men, and, conse- 
quently, disposed them to experience these attacks of night- 
mare. The constrained position in which they were obliged 
to lie, the fact of their not being undressed, and the bad air 
they were obliged to breathe, doubtless aided in the produc- 
tion." 

A gentleman was, not long since, under my professional 
charge who was very subject to attacks of nightmare. Though 
remarkable fo*r his personal courage, he confessed that dur- 



256 SLEEP. 

ing his paroxysms he was the most arrant coward in the 
world. Indeed, so powerful an impression had his frequent 
frightful dreams made upon him that he was afraid to go to 
sleep, and would often pass the night engaged in some occu- 
pation calculated to keep him awake. 

The dreams which he had were always of such a character 
as to inspire terror, and generally related to demons and 
strange animals, which seated themselves on his chest, and 
tried to tear open his throat. They came on a few minutes 
after he fell asleep, and lasted sometimes for more than an 
hour. During their continuance he remained perfectly still 
and quiet, giving no evidence of the tumult within beyond 
the appearance of a cold sweat over the whole surface of the 
body. When he awoke, as he always did when the climax 
was reached, he started from the bed with a bound, and with 
all the evidences of intense fright. After that he was safe for 
the remainder of the night. 

I am acquainted with another case in which there are no 
very obvious physical symptoms. 

Ordinarily, however, the sufferer groans, and tosses about 
the bed ; he appears to be endeavoring to speak, and to es- 
cape from his imaginary danger ; his face, neck, and chest 
are flushed ; a cold perspiration appears, especially on his 
forehead, and he is sometimes seized with a general trembling 
of the whole body. The respiration appears to be particularly 
disturbed ; he gasps for air, and occasionally the breathing is 
stertorous. As to the pulse, strange as it may appear, there 
is rarely any marked change from the healthy standard be- 
yond the slight irregularity induced by the disorder of the 
respiration. 

Among the mental symptoms, in addition to the fear with 
which he is filled, the sufferer is strongly impressed with a 
sense of his utter helplessness. His will is actively engaged 
in endeavoring to bring his muscles into action, but they can- 
not be made to obey its behests, and he consequently feels 
himself powerless to escape from the enemies which attack 
him. 

In regard to the kind of images which make their appear- 
ance, there is more or less uniformity. Generally they con- 
sist of animals, such as hogs, dogs, monkeys, or nonde- 
scripts created by the imagination of the dreamer. At other 
times they are demons of various forms. A gentleman, whose 



MORBID DREAMS. 257 

case came under my notice, was visited almost nightly by a 
huge black walrus, which appeared to roll off of a large cake 
of ice, and, crawling up the bed, to throw itself on his chest. 
Another was tormented by an animal, half lion and half mon- 
key, which seemed to fasten its claws in his throat while 
seated on his breast. 

At other times there are no images, but only painful delu- 
sions, in which the dreamer is placed in dangerous positions, 
or suffers some kind of torturing operation. Thus, a lady in- 
forms me that she is subject to frequent attacks of nightmare, 
during which she imagines she is standing on the top of a 
high mast, and in extreme fear of falling off. Again, she is 
dragged through a key -hole by some invisible power ; and 
again has her nose and mouth so tightly closed that she can 
get no breath of air. 

The causes of nightmare may be divided into the exciting 
and the immediate. The exciting causes are very numerous. 
Unusual fatigue, either of mind or of body, recent emotional 
disturbance, such as that produced by fright, anxiety, or an- 
ger, and intense mental excitement of any kind, may produce 
it. I have known a young lady to have a severe attack the 
night after a school examination, in which she had been un- 
duly tasked. Another young lady is sure to be attacked 
after witnessing a tragedy performed. A young man, who was 
under my care for a painful nervous affection, always had a 
paroxysm of nightmare during the first sleep after delivering 
an address, which he was obliged to do every month for a 
year or more. 

Fulness of the stomach, or the eating of indigestible or 
highly stimulating food late in the evening, will often cause 
nightmare. As Motet ' remarks : " One of the best-established 
causes is repletion of the stomach, and slowness and diffi- 
culty of digestion. Let an individual habitually systematic 
depart for one day from the accustomed regularity of his 
meals, let him change the hour of his dinner, and go to bed 
before the work of digestion is completed, and it is probable 
that his sleep will be troubled, and that nightmare will be 
the consequence of his indiscretion. The painful feeling will 
be induced by distention of the stomach, by anxiety, and by 
the restraint given to the movements of the diaphragm." 

1 " ^ouveau dictionnaire de medecine et de chirurgie pratiques," t. 6ieme, 
Paris, 1867, art. " Cauchemar." 
17 



258 SLEEP. 

Feculent food would appear to be especially powerful in 
causing nightmare, and, according to Motet, strong liquors and 
sparkling wines and coffee are equally so. I have several 
times known it produced by the New England dish of baked 
pork and beans, and by green Indian corn eaten just before 
going to bed. 

Various morbid affections, such as diseases of the heart, 
aneurism of the large arteries, affections of the brain or spinal 
cord, and diseases of the digestive or urinary apparatus, are 
often exciting causes of nightmare. It may originate from 
painful sensations in any part of the body. Some women, 
about the time of the menstrual flow, are particularly liable to 
paroxysms of this morbid dreaming. 

Whatever interferes with the respiration or the easy flow 
of blood to and from the head may bring on an attack of 
nightmare. I have known it caused by the collar of the 
night-gown being too tight, and by the pillow being under 
the head and not under the shoulders, thus putting the head 
at such an angle with the body as to constrict the blood-ves- 
sels of the neck, and by the head falling over the side of the 
bed. I have not been able to ascertain that sleeping upon the 
back or on the left side predisposes to the affection, unless in 
those cases in w^hich the former position causes snoring from 
relaxation of the soft palate. 

The immediate cause of nightmare is undoubtedly the cir- 
culation of blood through the brain which has not been suffi- 
ciently aerated. The appearance of the sufferer is sufficient 
to indicate this, as the condition of the cerebral vessels and 
all the exciting causes act either by retarding the flow of the 
venous blood from the brain or by impeding the respiratory 
movements. The effects of emotion, of mental fatigue, and 
of severe and long- continued muscular exertion, are such that 
the nervous influence to the muscles of respiration is increased 
or the muscles themselves are debilitated through this general 
fatigue of the organism. Fulness of the stomach acts me- 
chanically, by interfering with the action of the diaphragm, 
and constriction about the neck directly increases the flow of 
blood through the brain. Certain diseases of the heart and 
lungs act upon the function of respiration, and thus interfere 
with the due oxygenation of the blood. 

The treatment of morbid dreams presents no points of any 
difficulty. When they are the result of impressions made 



MORBID DREAMS. 259 

upon the nerves during sleep, and are the forerunners of dis- 
ease, it is not very likely that physicians will be consulted as 
to their cure. Undoubtedly, however, much can be done to 
abate them when they belong to the category of prodromic 
dreams, as well as when they are symptomatic of existing 
disease. Hygienic measures, such as open-air exercise, atten- 
tion to diet, and warm baths, and the use of the oxide of zinc 
and some one of the bromides, will do much to lessen the irri- 
tability of the nervous system, and to diminish any hyper- 
semic condition of the brain. 

Nightmare often requires more active management, though 
even here we will ordinarily find the measures above men- 
tioned the most effectual that can be taken for its treatment. 
Of course, the exciting cause must be ascertained if possible, 
and means taken to remove it. This is not always an easy 
matter, and frequently cannot be accomplished without a 
considerable alteration in the course of life followed by the 
patient, and more or less sacrifice on his part. Among hy- 
gienic measures, I have several times found relief follow a 
sojourn at the sea- shore and ocean bathing. Change of air 
is almost invariably beneficial, and moderate physical exer- 
cise, just to the point of fatigue, can scarcely be dispensed 
with. A gentleman, at this moment under my care, has been 
cured by a course of gymnastic training, which he took at 
my instance. The food of those subject to nightmare should 
always be plain, easily digestible, and moderate in quantity. 
Alcoholic beverages should always be sparingly taken, espe- 
cially just before going to bed. Any article of food or drink 
known to produce the paroxysm should, of course, be omitted 
altogether. 

As to medicines, the whole round of so-called anti-spas- 
modics is usually tried by routine physicians. I have never 
seen them do any good. Iron and bitter tonics are indicated 
in cases of ansemia or exhaustion. As the disease is some- 
times induced in children by the presence of worms in the 
alimentary canal, diligent inquiry should be made relative 
to symptoms indicating irritation from these parasites, and, 
if they are found to exist, anthelmintics should be adminis- 
tered. 

A case of intermittent nightmare, occurring every alternate 
night, in a young lady, was recently under my care. No ex- 
citing causes could be discovered, except the probable one of 



260 SLEEP. 

malaria. The affection yielded at once to the sulphate of 
quinia. 

Ferrez ' has published the details of a case of intermittent 
nightmare occurring in the person of a Spanish officer, who 
was attacked after passing forty-two nights at the bedside of 
a sick daughter. Every night, at the same hour, he was 
awakened by frightful dreams, which, irritating his brainy 
produced cramps, convulsive movements, an afflux of blood 
to the cerebral tissues, a sadness which he could not conquer, 
and a continual and powerful feeling of approaching death. 

The patient, though of strong constitution, became en- 
feebled and emaciated. His countenance was pale, 4 the pupils 
contracted, and his whole appearance showing the exhaustion 
consequent upon the battle which he was obliged continually 
to fight with his disease. He composed at this time some 
verses, describing in graphic terms the deplorable condition 
of his mind and body. 

Gymnastics, temperance in eating and drinking, and the 
study of poetry, failed to give him relief. Finally he con- 
sulted Dr. Ferrez, who advised him to reveal his state to his 
family, who hitherto had been kept in ignorance of his mal- 
ady, to continue his gymnastics moderately, not to eat in the 
evening, to drink only cold water, to use friction over the 
whole surface of the body, to apply mustard plasters to the 
extremities, to sleep with his head elevated and uncovered, 
to bathe his head frequently during the night with cold 
water, to give up the study of poetry, and to devote himself 
to mathematics and political economy. These measures were 
rigorously carried out ; but his daughter, who had been the 
involuntary cause of his disease, prescribed a better remedy 
than all the others. She had him waked at midnight, before 
the occurrence of his paroxysm, and thus broke up the habit. 

Perhaps no one medicine is so uniformly successful in the 
ordinary forms of nightmare as the bromide of potassium or 
of sodium, administered in doses of from twenty to forty 
grains, three times a day. I have seen a number of cases 
which have resisted all hygienic measures, and the simple 
removal of the apparent cause, yield to a few doses of this 
remedy. 

When the affection has lasted a long time, it is more diffi- 
cult to break up the acquired habit. In these cases, the plan 

1 " Gazette m6dicale de Lyon, 1 ' 15 Mai, 1856 ; also, Macario, op. cit., p. 104. 



MORBID DREAMS. 261 

so successfully employed by the daughter of the Spanish of- 
ficer will almost invariably succeed. 

Finally, persons subject to nightmare should so train the 
mind as to employ the intellectual faculties systematically 
by engaging in some study requiring their full exercise. The 
action of the emotions should be as much as possible con- 
trolled, and the reading of sensational stories, or hearing sen- 
sational plays, should be discouraged. By severe mental 
training, individuals can do much to regulate the character 
of their dreams. It is a well-recognized fact that intense 
thought upon subjects which require the highest degree of 
intellectual action is not favorable to the production of dreams 
of any kind. 



SECTION IV. 

DESCRIPTION AND TREATMENT OP 
INSANITY. 



CHAPTER I. 

DEFINITIONS AND DESCRIPTIONS. 

Nothing is more essential to a proper understanding of a 
subject, especially of so abstruse a one as insanity, as to have 
clear ideas of the meanings of the terms employed in its con- 
sideration ; and this is particularly necessary when there are 
wide-spread errors existing in regard to the signification of 
several of the words used to designate some of the most im- 
portant symptoms of the disease. It will be well, therefore, 
to start with exact notions of what we mean when these words 
are employed. 

Definition of Insanity. — Every medical witness who appears 
in a case involving the mental capacity or responsibility 
of an individual is expected to give a definition of insanity. 
It is extremely difficult to do this satisfactorily, as it is also 
with a good many other terms which are applied to complex 
forces, for the definition should cover all possible cases of defi- 
ciency or aberration of the mental faculties, and yet not in- 
clude those instances of cerebral disease which cannot prop- 
erly be classed under this head. For the purpose of showing 
how authors have varied in their ideas of the signification of 
the word, as well as for the instruction of the reader seeking 
for information on the point, I quote a number of definitions 
from some of the most eminent authorities. 

Dr. John Haslam, 1 who has written one of the most lucid 
treatises on insanity in the English language, and who was 

1 " Observations on Madness and Melancholy," etc., London, 1809, p. 37. 



DEFINITIONS AND DESCRIPTIONS. 263 

for many years one of the physicians to Bethlehem Hospital, 
confesses his inability to give a thoroughly comprehensive, 
and yet a sufficiently exhaustive, definition of madness ; and 
Dr. Prichard ' frankly admits that it is better to give up the 
attempt to define insanity in general terms. Notwithstanding 
the reluctance of these and other medical authorities to f or- 
mularize the phenomena of insanity, the attempt has fre- 
quently been made with more or less approach to complete- 
ness. If the word can be even imperfectly defined in simple 
language without conveying erroneous ideas, it is certainly 
advisable to make an effort in this direction. 

According to Hoffbauer, 2 an individual is insane when the 
understanding is diverted or changed in its operations ; when 
he is powerless to avail himself of his intellectual faculties, or 
to make known his wishes in a suitable manner. 

This definition neither embraces all kinds of insanity, nor 
excludes certain cerebral disorders which are not properly 
classed under this head. For instance, it does not compre- 
hend morbid impulse, the subjects of which often evince no 
derangement of the understanding or intellect, and it includes 
apoplexy, and concussion and compression of the brain. 

Dr. Bucknill 3 defines insanity as " a condition of the mind 
in which a false action of conception or judgment, a defective 
power of the will, or an uncontrollable violence of the emo- 
tions and instincts, has separately or jointly been produced 
by disease." 

According to this definition, the individual who is coma- 
tose from the effects of a cerebral haemorrhage or a blow on 
the head, and who certainly has a " defective power of the 
will " produced by disease, is insane. 

Dr. Guislain, 4 an eminent Belgian authority, says that in- 
sanity is 

" A chronic disease, free from fever, in which the ideas and 
the acts are under the control of an irresistible power, a change 
taking place in the manner of feeling, conceiving, thinking, 
and acting peculiar to the individual, in his character and in 
his habits ; a state which contrasts with the sentiments, the 

1 Art. " Insanity " in " Cyclopaedia of Practical Medicine." 

8 " Untersuchungen Uber die Krankheiten der Seele," Halle, 1803, p. 11. 

3 " Unsoundness of Mind in relation to Criminal Acts," second edition, 1857. 

4 Lecons orales sur les phrenopatkies," etc., Gand— Paris, 1880, second edition, 
t. i, p. 52. 



26± DESCRIPTION AND TREATMENT OF INSANITY. 

thoughts, and the acts of those about him ; an affection which 
renders it impossible for him to act so as to provide for his 
preservation, and with a sense of his responsibility to God or 
to society." 

The objections to this definition are, that insanity is not 
necessarily unaccompanied by fever, that it is not always a 
chronic affection, and that it, like the others mentioned, in- 
cludes too much. 

Drs. Bucknill and Tuke, ' in the first edition of their work 
on insanity, quoting from Maimon, say that " mental health 
consists in that state in which the will is free, and in which it 
can exercise its empire without obstacle. Any condition dif- 
ferent to this is a disease of the mind. And if it be asked, 
What is the Will % it may be replied, according to the defini- 
tion of Marc, that it is in health a moral faculty, which origi- 
nates, directs, prevents, or modifies the physical or moral acts 
which are submitted to it." 

More recently, however, they a state that they believe it im- 
practicable to propose any definition entirely free from objec- 
tion, and which shall comprise every form of mental disorder. 
They, therefore, omit the partial definition above given, and 
announce 3 a qualified adherence to the one previously given 
by Dr. Bucknill. 

The late Professor Grilman, 4 of this city, who had given a 
great deal of study to the subject, declared that the best defi- 
nition he had been able to make was, that " insanity is a dis- 
ease of the brain by which the freedom of the will is im- 
paired." 

This definition neither covers the subject nor excludes other 
diseases. 

Dr. Thomas K. Cruse B has given a definition of insanity 
far in advance of any of those cited. For him "insanity is a 
psychic manifestation of brain disease." The only objection 
to be urged against this definition, which, in a few words, em- 
braces every form of insanity, is, that it includes too much. 
A man insensible from the effects of cerebral hemorrhage 

1 "A Manual of Psychological Medicine," etc., London, 1858, p. 79. 

2 " A Manual of Psychological Medicine," etc., fourth edition, London, 1879, 
p. 19. 8 Op. cit., p. 23. 

4 " The Relations of the Medical to the Legal Profession," p. 20. 
6 "A New Definition of Insanity," Journal of Psychological Medicine, April, 
1872, p. 267. 



DEFINITIONS AND DESCRIPTIONS. 265 

exhibits a "psychic manifestation of brain disease," but he 
certainly is not insane. 

Dr. E. C. Spitzka 1 has proposed a very comprehensive 
definition, which, with, some modifications, may be made suffi- 
ciently complete and satisfactory. It is : 

"Insanity is either the inability of the individual to cor- 
rectly register impressions and experiences in sufficient number 
to serve as rational guides to rational behavior in consonance 
with the individual's age, time, and circumstances, or, such 
impressions and experiences being correctly accumulated in 
sufficient number, a failure to co-ordinate them, and thereon 
form logical conclusions, or any other gross mental incon- 
gruity with the individual's surroundings in the shape of sub- 
jective manifestations of cerebral disease or defect, excluding 
the phenomena of sleep, trance, somnambulism, the ordinary 
manifestations of the neuroses, such as epilepsy and hysteria, 
of febrile delirium, coma, acute intoxication, and the ordinary 
immediate results of nervous shock and injury." This defini- 
tion, however, excludes all morbid impulses, and all emotional 
and volitional manifestations of mental derangement. 

It would be easy to go on and quote numerous other 
authorities on this point, but enough have been cited to show 
the general import which physicians give to the word "in- 
sanity." I will, therefore, dismiss the further consideration 
of this division of the subject by stating that my own idea of 
insanity is based entirely on the fact that as a healthy 
mind results from a healthy brain, so a disordered mind 
comes from a diseased brain. Insanity, therefore, strictly 
speaking, is only a symptom of cerebral disease, and I would 
define it as — 

A manifestation of disease of the brain, characterized by a 
general or partial derangement of one or more faculties of the 
mind, and in which, while consciousness is not abolished, 
mental freedom is weakened, perverted, or destroyed. 3 

An essential feature of the definition here given is, that it 
is directly the result of a diseased condition of the brain. 
This is the immediate cause, and may consist of structural 
changes due to injury, disease, or malformation; or malnu- 
trition, the result of excessive intellectual exertion, the ac- 

1 " A Practical Definition of Insanity," Chicago Medical Review, July 15, 1882. 

2 See "A Treatise on Diseases of the Nervous System," first edition, 1871, 
p. 334 ; also, subsequent editions up to and including the sixth. 



266 DESCRIPTION AND TREATMENT OF INSANITY. 

tion of powerful emotions, irritations in distant parts of the 
body, the sudden stoppage of the digestive process, the in- 
troduction into the system of certain drugs — such as opium, 
alcohol, belladonna, etc. — the retention in the organism of 
substances poisonous in character, but which, in health, are 
excreted as some of the constituents of the bile or the urine, 
and of other factors capable of altering the quantity or qual- 
ity of the blood circulating through the cerebral vessels, or of 
accelerating or retarding the metamorphosis of tissue which 
the brain undergoes in common with all the other organs of 
the body. 

This definition, so far as I can perceive, excludes no form 
of insanity, nor does it include diseases which are not insan- 
ity. It rests upon the basis of brain disease, without which 
there can, in my opinion, be no insanity. 

But, with a little modification, Br. Cruse' s definition, pre- 
viously cited, can be made to exclude the manifestations of 
brain disease which are not usually comprehended under the 
term insanity. I would propose to add to it the words un- 
attended oy loss of consciousness. It will then read: "A 
psychic manifestation of brain disease unattended by loss of 
consciousness." In this form, it is shorter than and as com- 
prehensive as my own, and perhaps is, on these accounts, to 
be preferred. 

Illusion. — An illusion is a false perception of a real sensori- 
al impression. Thus, a person seeing a ball roll over the floor, 
and obtaining from it the perception that it is a mouse, has an 
illusion of the sense of sight ; another, hearing the pattering 
of the rain on the roof, and perceiving in this sound the voice 
of some one calling him, has an illusion of the sense of hear- 
ing ; another, having some bitter substance placed on his 
tongue, and forming the perception of a sweet flavor, has an il- 
lusion of the sense of taste ; another, smelling a bottle of Co- 
logne-water, and receiving the impression of turpentine in the 
nostrils, has an illusion of the sense of smell ; and another, 
rubbing the tips of his fingers over a smooth plate of glass 
and obtaining a sensation like that derived from contact with 
sand-paper, has an illusion of the sense of touch. In all such 
cases there is a material basis for the perception, but, owing 
to disorder or disease of the sensorial organ, the nerves by 
which the impression received is conveyed to the brain, or 
of the perceptional ganglion, an erroneous perception is pro- 



DEFimTIONS AND DESCPwIPTIONS. 267 

duced — and, consequently, the normal relation between the 
cause and the effect is disturbed. 

Illusions are not always indicative of the existence of in- 
sanity, or even of cerebral disorder. It is, perhaps, never the 
case that the perception is precisely in accordance with the 
real properties of the substance making the sensorial impres- 
sion. We never see, hear, taste, smell, or feel things exactly as 
they are. This imperfection may be due to the fact that the 
surrounding circumstances are not favorable. Insufficient 
light may thus make our vision imperfect ; a thing, for in- 
stance, may seem to be of a green color when it is in reality 
blue ; loud noises may make us incapable of perfectly appre- 
ciating the character of gentle sounds ; a strongly sapid sub- 
stance rubbed over the tongue and fauces prevents us distin- 
guishing delicate flavors ; a powerful odor may make such an 
impression on the Schneiderian membrane that other odors 
for a long time smell like it ; and exposure to very cold 
weather interferes markedly with the discriminating power of 
the sense of touch. 

Imperfect perceptions are often formed in consequence of 
the perceptive ganglia being otherwise occupied. Thus, if 
we are looking intently at some object of interest, we are not 
apt to attend to the sounds that reach our ears, and, conse- 
quently, no clear perception of them is formed. 

Illusions of all the senses, but especially of sight and hear- 
ing, are met with in insanity, and particularly in those acute 
forms characterized by the presence of delirium. They may 
also exist as diseases without the higher faculties of the 
mind being involved, but this is not a common circumstance. 
Usually the persistent presence of illusions is evidence of 
brain disease, which, if not already involving the intellect, 
the emotions, or the will, is particularly liable so to do at no 
very distant date. 

Hallucination. — A hallucination is a false perception, with- 
out any material basis, and is, therefore, centric in its origin. 
It is more, therefore, than an erroneous interpretation of a 
real object, for it is entirely formed by the mind. An indi- 
vidual, who on looking at a blank wall perceives it to be cov- 
ered with pictures, has a hallucination of the sense of sight ; 
another, who, when no sounds reach his ears, hears voices 
whispering to him, has also a hallucination, but it is of the 
sense of hearing — and such false perceptions may be created 



26S DESCRIPTION AND TREATMENT OF INSANITY. 

as regards all kinds of sensorial excitations. The organs of the 
senses are, in fact, not necessary to the existence of hallucina- 
tions. Thus, if the eyes be closed, images may still be seen ; 
if the hearing be lost, voices may still be heard, and the reason 
for this is found in the fact that the erroneous perception con- 
stituting the hallucination is found in that part of the brain 
which ordinarily requires the excitation of a sensorial impres- 
sion for its f unctionation. A remarkable instance of this fact 
has come under my observation, in which an old lady, abso- 
lutely deaf, not being able, in fact, to hear thunder or the 
noise caused by the discharge of a cannon, was constantly 
troubled by imaginary voices whispering in her ears. The 
blind are very often subject to hallucinations of sight. 

But hallucinations of any sense cannot exist unless the 
individual has, at some time or other, possessed the use of 
that sense. A person, for instance, born blind or deaf, can- 
not have hallucinations of sight or hearing until the one or 
other of these senses has been given to him ; and, if they are 
never given, he will remain all his life incapable of having 
hallucinations of the kind referred to. I have had the oppor- 
tunity of studying the case of a man born with double cata- 
racts, who remained blind till his fourteenth year, when he was 
operated upon by a surgeon in Berlin. Previous to that time 
he had never had hallucinations of sight, but, after the oper- 
ation, he became subject to these false perceptions. Coming 
to this country, he was again rendered blind by ophthalmic 
inflammation, caused by the premature explosion of a blast, 
but the hallucinations persisted, though he was unable to tell 
light from darkness. 

Hallucinations are always evidence of cerebral derange- 
ment, and are common phenomena of insanity. They may be 
excited by emotions of various kinds, by which the character 
and quantity of blood circulating within the cranium are 
changed, by excessive intellectual exertion, by mechanical im- 
pediments to the return of blood from the brain, by various 
diseases which, directly or indirectly, affect the encephalon, 
by certain drugs, and by other factors presently to be more 
fully considered. 

Delusion. — Illusions and hallucinations may exist, and the 
individual be perfectly sensible that they are not reali- 
ties. In such cases the intelligence is not involved. But, if 
he accepts his false perceptions as facts, his intellect partici- 



DEFINITIONS AND DESCRIPTIONS. 269 

pates, and lie has delusions. A delusion, therefore, may be 
based upon an illusion or a hallucination. It may also result 
from false reasoning in regard to real occurrences, or be 
evolved out of the intellect spontaneously, as the result of 
imperfect information, or of an inability to weigh evidence, or 
to discriminate between the true and the false. Delusions are 
not a test of insanity, as most lawyers and many physicians 
believe. If they were, one half the world would be trying to 
put the other half into lunatic asylums. They may be present 
without coexistent insanity, and many cases of mental aber- 
ration run their course without them. 

To be indicative of the existence of insanity, a delusion 
must relate to a matter of fact, be contrary to the customary 
mode of thought of the individual, and held in opposition 
to such evidence as is logically opposed thereto. Beliefs 
in regard to matters of faith, however ridiculous they may 
be, are not necessarily proofs that the individual holding 
them is insane. Thus, a believer in spiritualism may be per- 
fectly sane, for his belief is one not capable of proof or dis- 
proof. It is a part of his mentality to believe in the existence 
of spirits, and in the possibility of calling them so as to see 
and talk with them ; moreover, he has probably at some time 
or other been deceived by impostors, who have passed off 
material objects upon him as immaterial and spiritual, and 
he has not had the opportunity or the desire to investigate 
the matter and to expose the fraud. But, if a non-believer 
in the system of spiritualism, should imagine that he was 
in the habit of seeing spirits and of conversing with them, the 
fact would be good evidence of his insanity. There would 
hence be hallucinations, and a delusion resulting from them 
and relating to a matter of fact ; and, further, though the 
spiritualist might believe in the existence of spirits capable of 
making themselves visible, wearing textile fabrics, and talking, 
and still be sane, yet, if he believed, without foundation and 
contrary to positive evidence, that his brother had tried to 
poison him, he would have a delusion sufficient to indicate 
his insanity. 

At a former period of the world' s history a belief in the 
possibility of seeing devils and demons of various kinds, and 
of suffering from their torments, was commonly entertained. 
Indeed, it is religiously held now by a good many otherwise 
sensible people. Such a belief is, according to my mode of 



270 DESCRIPTION AND TREATMENT OF INSANITY. 

thought, a delusion ; and probably nine tenths of those who 
read this treatise will agree with me in so regarding it. But 
it certainly would not be safe to consider every one holding 
such a creed as insane. The number who accept such a belief 
is daily becoming smaller, and eventually the time will come 
when, from a change of the modes of thought due to progres- 
sive enlightenment, an educated person, believing that there 
are evil spirits commissioned by a sovereign, the devil, to afflict 
mankind with various ills, will be regarded as a lunatic. The 
acceptance of such a belief will be considered as showing the 
existence of a state of mind incompatible with a healthy con- 
dition of the brain. At the present day the brain of man has 
not acquired such an average advanced state of development 
as to enable us to declare that a belief of the kind mentioned 
is any indication of the presence of disease, however much it 
may be evidence of deficient education and training. 

A like reasoning applies to the holders of every other form 
of belief accepted as an article of faith not susceptible of 
proof. 

A delusion, therefore, to be an indication of the existence 
of insanity, must relate to a matter of fact, must be such a 
belief as would not be entertained in the ordinary normal 
condition of the individual, must have been formed without 
such evidence as would have been necessary to convince in 
health, and must be held against such positive testimony as 
would in health have sufficed for its eradication. 

As above stated, a delusion, to be evidence of the existence 
of insanity, must relate to a matter of fact in regard to which 
testimony may be taken and its truth or falsehood demon- 
strated. A normally constituted mind cannot refuse to accept 
a demonstration if its elements are of such a character as to 
be within the degree of development of the brain of the indi- 
vidual. Thus, a person of ordinary intelligence and education 
will comprehend a demonstration of one of the problems of 
Euclid, which a man with a brain free from disease, but which 
has not been educated, will not be able to understand. Nev- 
ertheless, he has the capacity for comprehension, and this ca- 
pacity only requires education. If another, who at one time 
fully understood all the problems of geometry, should lose this 
power, it would be very strong evidence of his insanity ; and 
if another, not accustomed to believe impossible or improbable 
things, imbibes a belief without there being any evidence to 



DEFINITIONS AND DESCRIPTIONS. 271 

support it, and clings tenaciously to it, notwithstanding its 
improbability and the facts which are brought to show its 
untruth, he would certainly be insane. 

But, no matter how improbable or absurd the religious be- 
lief of an individual may appear to us to be, it would not 
show him to be insane, for it would relate altogether to a 
matter of faith in regard to which certain knowledge could 
not be brought to bear. Thus, in the case of Louis Bonard, a 
Frenchman, who died a few years ago in this city, it was in 
evidence that the deceased had entertained the belief of me- 
tempsychosis, and the attempt was made before the surrogate 
of the city and county of New York to set aside the will by 
which he bequeathed his tolerably large estate to the Society 
for the Prevention of Cruelty to Animals, on the ground that 
metempsychosis was a delusion, and that an individual 
brought up in a Christian community who believed in it was 
insane. My opinion on the subject was requested by the pro- 
ponents of the will, and I stated in the Surrogate's Court 
that "no religious belief, no matter how absurd it may be, is 
of itself sufficient evidence of a man's insanity. I base that 
answer upon the investigation of a large number of cases, 
and likewise upon a very thorough reading of the subject. 
As regards the doctrine of the transmigration of souls and 
the doctrine of metempsychosis — because, I think, there is a 
distinction between them — both have been held, at various 
times of the world's history, by the most enlightened nations 
then on the earth. They were, and are at the present day, 
held by the Hindoos, by the people of Siam, by the people 
of Thibet, by the Chinese. They were held by the ancient 
Egyptians, Greeks, Persians, Scythians, by the Druids, and by 
the Celts generally, to some extent. They are held now by 
the North American and South American Indians, as I know 
of my own knowledge in regard to the North American In- 
dians. They were held by various heretical sects among the 
early Christians, and especially by the Gnostics and Maniche- 
ans, who were early heretical sects. They have likewise been 
held by several distinguished European men — Pythagoras, 
Plato, Pericles, Plotinus ; by Origen, by Fourier, by Lessing ; 
and among writers of the present day by Pierre Leroux ; and 
Fourier has written extensively on the subject. I know of 
my own knowledge that they are held at the present day by 
people in the city of New York. I may say that Mr. Alger, 



272 DESCRIPTION AND TREATMENT OF INSANITY. 

in his very learned work, 'The Doctrine of a Future Life,' 
declares from his own knowledge that these beliefs, in some 
form or other, are largely held in this country and in Europe 
at the present day." 

In deciding to admit the will to probate, the surrogate, in 
adopting these views, said : 

" It appears to me that, if a judicial officer should assume 
that merely because a man believed in that doctrine [metemp- 
sychosis] he was insane, or acted under an insane delusion 
or monomania incapacitating him from making a will, if 
prompted by that faith, but though consistent with it, wholly 
rational in its provisions, it would not fall far short in princi- 
ple of assuming that all mankind who do not believe in the 
particular faith which the judge accepts respecting a future 
state are more or less insane, or the victims of an insane delu- 
sion. 

" This question is entirely within the domain of opinion 
or faith, and not of knowledge. A man may properly be as- 
sumed insane upon evidence that he is governed by halluci- 
nations which are physically impossible to the knowledge of 
all sane men, and which are contrary to the evidence of the 
senses, or who is influenced by delusions which are the cre- 
ation of diseased reflective faculties. 

" Hence, the opinion as to a future state, of which no man 
has positive knowledge, and in regard to which mankind 
have always differed, and so widely differ to-day, even in the 
most civilized communities and among the most intellectual 
of men, cannot in any respect be deemed evidence of insanity, 
the only rule by which the insanity of one of certain opinions 
can be determined being by some test founded on positive 
knowledge." 1 

I have considered this point at some length, for the reason 
that I am aware that a good deal of misapprehension exists in 
the minds of physicians and lawyers relative to the essential 
nature of a delusion which is to be evidence of an individual's 
insanity. The distinction between a belief founded on faith 
and one founded on fact is not always recognized, and we are 
all more or less apt, unless we guard ourselves closely, to 
look upon those who hold what we consider erroneous convic- 
tions as being the victims of insane delusions, when, in reality, 

1 "Abbot's Reports of Practice, Cases determined in the Courts of the State 
of New York," vol. xvi, Nos. 2 and 3, p. 128, et seq. 



DEFINITIONS AND DESCRIPTIONS. 273 

the matter in question is entirely beyond the pale of investi- 
gation by the rales of evidence. 

But there are certain delusions, mostly of a religious charac- 
ter, which, though partly based on faith, may urge the subject 
to the perpetration of some act of criminal violence. An indi- 
vidual may, for instance, imbibe the belief that God has or- 
dered him to kill his son on a certain day, and when the time 
comes round he murders his child. Such a belief cannot be 
controverted by evidence, because there is no attainable testi- 
mony which can be brought to bear upon the matter. The 
man persists that he knows it to be true, that he was told 
what to do in a dream, and he adduces text after text from 
the Bible to prove that there is nothing in his conduct unbe- 
coming a believer in God, and of one acknowledging his power. 
Such a man, if really holding to the belief in question, must, 
nevertheless, be pronounced insane, for it is one not only of 
faith, but of fact also. He might believe in God's power to 
order him to kill his son, and in his right to do so : that would 
be entirely a matter of faith ; but when he adds to this the 
belief that God actually did order him to do so, the element of 
fact is brought in, and an insane delusion exists. 

As I have said, insanity may exist without delusions being 
at any time present. Some physicians doubt this fact, but 
this is due to the circumstance that they have no clear con- 
ception of what a delusion is. I have heard the superintend- 
ent of a lunatic asylum state that all attempts of the insane 
to commit suicide or homicide were the results of delusions, 
and, when I requested to be informed as to the understanding 
in his mind of the nature of a delusion, he replied that "any 
notable deviation of the mind from its usual and accustomed 
standard was a delusion." We see, therefore, how necessary 
it is that we should have in the study of insanity exact ideas 
of the meaning of the words we employ. 

Incoherence. — There are two kinds of incoherence : 

1. That in which the words used in speaking or writing 
are without proper relation to each other. 

2. That in which the ideas are without logical arrange- 
ment, or are incompletely expressed. 

Not infrequently both kinds exist in the same individual. 
As an example of the first-named variety of incoherence, I 
cite the following letter : 

18 



274 DESCRIPTION AND TREATMENT OF INSANITY. 

"In the Neck, January 7, 1871. 

" Dear Sir : I said lie was in my own conscience that the 
book was confined. I quote the long time with eccentricity in 
the common way. This is in memory to my upshot, which was 
incorrect in the final oblivion. Dogs and money, consistency 
with foundlings without antebellum, which was in statu quo. 

" This is passive in contiguity with the works met in the 
creation of existence. " Yery commingle, 

"In good faith, 
«j. s. W— ." 

The patient who wrote this was at the time suffering from 
an attack of acute mania. Although no one not familiar with 
his case can obtain an idea of what he was thinking of when he 
wrote this letter, or rather of what he was endeavoring to think, 
I — knowing the cause of his insanity, and the predominating 
thoughts present with him at the time he became insane, and 
during the prodromatic stage, when his mind was not yet over- 
thrown — can discover here and there the vestige of an idea. 
He was a young man who had, without much preliminary 
training, entered upon the task of refuting Darwin's views 
relative to the " Descent of Man," and who had written quite 
a large volume on the subject. He had labored very assidu- 
ously at his undertaking, and had consulted a large number 
of authorities, frequenting the public libraries, and sitting up 
late at night at his work. Finally he broke down. His letter 
refers indistinctly to his book, and the words "dogs" and 
"works met in the creation of existence" indicate subjects 
that he had been engaged in studying. 

The following "poem" was written by a lady who was 
also suffering from acute mania, with slightly erotic tenden- 
cies. As is seen, the words used to express each idea are 
logically arranged, but there is no proper relation between 
the ideas. Each is, in fact, entirely independent of the others : 
"I stood upon the awful height 
To be my funeral shroud ; 
Oh, how can Heaven reveal its light, 
And then to him she bowed. 

"Come, come with me, my gentle youth, 
Sleep wafted o'er my soul, 
I am a maid, called Ruby Ruth, 
So sadly I condole." 



DEFINITIONS AND DESCRIPTIONS. 275 

The following is from the " Evening Post " of abont three 
years ago. It is an excellent example in the first part of in- 
coherence of ideas, and in the latter of incoherence of words. 
I cite it, with the editor's remarks, as printed at the time : 

" [For the ' Evening Post.'] 

"LES OISCA^TY SOLITAIRES. 

" [Usually we have an opinion about the verse sent to us. The 
following piece, which appears to be of noble origin, goes beyond our 
comprehension. We leave it to the judgment of the reader.] 
" Closely watch'd — Juvenile Bridal Dress : 

Arch summer smiles. Dreaming ever of thee. 

My desolate heart no longer throbs 

Lifted hand — sad — why wearily ? 

I listen in spirit the Sea Gull's call. 

The story runs, that, disheartened the child ran away — Gone ! 

Worn-cast- down-look. September evening breeze, 

Gray Mist dissolves. Peeps ! Love's honey'd kiss, chaste as the 
dawn. 

" Lord of the Dead Sea : more by right ! Crisp hair 
Beams ! Filigree, Shabby Dress ! Soothing idle hours — 
Hopes cunning chaplet. Little Baggage, wreaths, 
Enchanted, Immaculate Flowers. 
Temp'rate Isles yield Candy tuft. Daysparkles 
Turning Fickle Youth : Ma Foi ! Time Glides ! Unmerited disdain ! 
Toy Baskets surfeit unruly sycophants : Ruffle Green, violet chene, 
Polands advance, white Parasols, depots John Leach haunts. No 
longer seen. 

" Countess or Brightwell. 
" Bkookltx, October 3, 1879." 

It often happens that insane persons, who exhibit inco- 
herence in their writings, nevertheless converse without any 
marked manifestation of this symptom. They seem to reqnire 
the stimulus of intercourse with others in order to arrange 
their words or ideas correctly, and when left to themselves 
are unable to do so. Again, some will express themselves with 
entire coherence until they begin to get tired, when they 
break down, and their words and ideas become disarranged, 
or the like result may ensue from gradually advancing excite- 
ment as the conversation goes on. Morel ' refers to the case 

1 Cited by Dagouet. " Xouveau traite elementaire et pratique des maladies 
mentales," Paris, 1876, p. 49. 



276 DESCRIPTION AND TREATMENT OF INSANITY. 

of a lunatic who, at the beginning of a conversation, was 
calm and reasonable, but who, if it was continued, became 
excited little by little ; his eyes shone brightly, his counte- 
nance assumed an expression impossible to describe, and very 
soon his words, his ideas, his gestures — in short, his whole 
appearance and all his actions — became ' those of a maniac in 
a violent paroxysm. Excitement produces a similar effect, 
though, of course, not to so great an extent, in many persons 
of perfectly sane minds. 

Incoherence is a prominent feature in delirium. It is gen- 
erally present at some time or other in cases of acute mania, 
and is common in imbecility, and in chronic insanity of any 
kind. It appears to be directly due either to the impossibility 
of keeping the attention sufficiently long on one idea for its 
full consideration, or to a difficulty of co-ordinating those 
parts of the brain which are concerned in the formation and 
expression of thoughts so as to obtain continuity of mental 
action. 

Delirium. — Delirium is that condition in which there are 
illusions, hallucinations, delusions, and incoherence, together 
with a general excess of motility, an inability to sleep, and 
acceleration of pulse. The derivation of the word, de, out of, 
and liro, a rut or furrow, sufficiently indicates the idea enter- 
tained by the ancients of the essential nature of the condition 
in question. 

Foville * has described two species of delirium : that which 
occurs in acute diseases generally, and in other conditions not 
insanity, and that which is met with in cases of mental aber- 
ration. The first class, however, embraces many different 
kinds, such as the delirium of starvation, the delirium due to 
toxic agents taken into the system, that which follows on 
wounds and injuries, and that which is sometimes met with 
in extreme old age. However, we need not at present con- 
cern ourselves with these varieties. A few words, neverthe- 
less, relative to the characteristics of the delirium of insanity 
will not be out of place. 

The condition may make its appearance suddenly, but 
usually it is of gradual development, being preceded by many 
signs of mental and physical disturbance. The perceptions, 
the intellect, the emotions, and the will may, singly or in 

^rt. "Delire," Nouveau dictionnaire de medicine et de chirurgie pratiques, 
t. xi, p. 1. 



DEFINITIONS AND DESCRIPTIONS. 277 

combination, be involved. Generally speaking, illusions and 
hallucinations are the most prominent features, the patient 
being entirely aware of their true character, conversing of 
them rationally, and willing to take proper measures to get 
rid of them. Erroneous ideas are at first distinctly recog- 
nized as abnormal, he laments the emotional disturbance of 
which he may be the subject, and regrets that he cannot bet- 
ter restrain himself from perpetrating disorderly or eccentric 
acts. With this implication of the mental faculties there is 
a disposition to talk incessantly, and, of course, somewhat 
wildly ; there is an exaggeration of motility, extravagant and 
excessive gestures are employed, and the patient is up and 
down through the day and night, now in this place and now in 
that, button-holing those he knows, and often those with whom 
he has no acquaintance, and telling them of the schemes he 
has in hand, or the persecution of which he is the victim. 
The delusion of persecution is a common phase of the dis- 
order, and, to escape from the enemies which he imagines are 
conspiring against him, he may wander off unintelligently, or 
depart secretly for some distant place. 

Esquirol ■ has given a short description of delirium which, 
so far as its mental manifestations are concerned, is very 
accurate. 

" A man," he says, "is in a state of delirium when his 
sensations are not in relation with exterior objects, when his 
ideas are not in relation with his sensations, when his judg- 
ments and his determinations are not in relation with his 
ideas, and when his ideas, his judgments, and his determi- 
nations are independent of his will." 

Delirium may be the first stage of any variety of insanity, 
though it is most common in the beginning of acute mania. I 
have seen several cases in which it was the first obvious sign 
of the existence of general paralysis of the insane. In one of 
them, the patient, a gentleman engaged in a large mercantile 
business, left his office at about three o' clock in order to take 
a drive in the Central Park. Up to that time, no one who 
had had any relations with him had noticed the slightest 
evidence of mental derangement. He drove up town in a cab, 
and never left it till he arrived at his own door. His wife was 
in the library waiting for him, but, as soon as he reached the 
room, she perceived that he was not right. His clothes were 
1 "Des maladies mentales," Paris, 1838, t. i, p. 5. 



278 DESCRIPTION" AND TREATMENT OF INSANITY. 

in disorder, his eyes were extraordinarily bright, he was ges- 
ticulating violently, he was alternately laughing and crying, 
and she could not understand a word of his incoherent and 
voluble speech. From that time on the signs of serious 
mental disorder became more apparent, and eventually there 
was no doubt of the existence of general, paralysis. 

In such cases as the foregoing, there were probably earlier 
symptoms, which from their lightness escaped observation, 
but of which the patient was himself fully aware. 

Although the erroneous perceptions and ideas may suc- 
ceed each other with great rapidity, there is not always such 
a degree of incoherence as to prevent the patient being under- 
stood. Still, I think there is always some disturbance in the 
faculty of speech. Words are misplaced or mispronounced, 
or entirely forgotten, or the individual, attempting to make 
his articulation keep pace with his ideas, only succeeds in 
making himself difficult to be understood. 

If the patient has in his or her normal condition been 
musically inclined, the proclivity is very apt to be increased 
in delirium, and hours are spent at the piano or some other 
musical instrument, or in singing at the top of the voice. 
Bergman * has called attention to a singular tendency, occa- 
sionally manifested by individuals in delirium, to the forma- 
tion of rhymes. One case of the kind has come under my 
observation in which the patient, a clergyman of about forty 
years of age, began to show evidences of mental aberration 
by excitement of mind and body, and in a short time by 
speaking and writing altogether in rhymes, or, as he called 
it, " rhythmical inspiration." The following is a portion of a 
letter I received from him at the time he was advised to con- 
sult me : 

"Dear Sir : If thus you'll allow me to call you, 
I write to inform you that my friend Mr. Ballou 
Has advised me to see you in regard to my health, 
If my means will admit ; for I have but small wealth ; 
I'm a preacher, and have but little of this world's goods 
Beyond a small salary and a little house in the backwoods. 
I shall leave here on the 4th — that is, Wednesday next — 
And will be in your city, if by railroads not vexed, 
On the following Saturday, and hope there you to meet 
At your city residence in Fifty-fourth Street, 

lu Nasse's Zeitsclirift fur psychologischen Aerzte," 1823, B. II, s. 419. 



DEFINITIONS AND DESCRIPTIONS. 279 

Say at ten o'clock, if that hour suits, 

And if it does not, it makes little difference to me, for I 
shall be entirely at your disposal." 
He even went so far as to prepare a sermon in rhyme, and 
was with difficulty prevented preaching it. I quote a few 
lines from this production : 

" I see before me many a face 
That but for God Almighty's grace 
Would sink into the depths of hell, 
And there in endless torments dwell. 
You sit regardless of your fate, 
Perhaps you'll stay till it is too late 
To save your weak and sinful souls 
From the lake that in fire and sulphur rolls. 
The devil and all his fiends are there, 
Waiting to seize you by the hair, 
To drag you down to the deepest pit 
And keep you there by God's permit." 
And so on for thirty-one pages. 

Whatever we may think of the poetry of this sermon, it 
must be admitted that its orthodoxy is unquestionable. 

When he entered my consulting-room, he advanced, hold- 
ing out his hand, and, with a smile on his face, said : 

" Good-morning, Dr. Hammond, I hope you are well, 
I've come a long distance my story to tell : 
They say I'm insane, but that's an inanity, 
I've a rhyming inspiration, but that's not insanity." 
His whole conversation was in rhyme, or the attempt 
at it, for occasionally he failed to get the word he wanted, 
and then he would "drop into prose" for a few sentences. 
He lost his rhyming inspiration in a few days after I saw 
him, and passed through an attack of acute mania and de- 
mentia, eventually recovering and returning to his duties with 
his congregation. 

Lucid Interval. — By the term lucid interval is to be under- 
stood a condition in which there is a total cessation of the 
symptoms of mental aberration and a complete restoration 
to reason occurring between any two paroxysms of insanity. 
With this understanding of a lucid interval it must be re- 
garded as a rare occurrence. In fact, it probably does not ex- 
ist except in the recurrent and epileptic forms of insanity, and 
in certain varieties of monomania and of morbid impulses. As 



2S0 DESCRIPTION AND TREATMENT OF INSANITY. 

thus defined, it differs essentially from those remissions 
which occur in the violence of all kinds of mentaj aberra- 
tion, and in which, while to a superficial observer the patient 
is sane, careful investigation by a skilful physician will not 
fail to reveal the evidences of unsoundness of mind. It is 
necessary to draw the line closely between these two condi- 
tions, and this is especially necessary in many medico-legal 
cases, in which it is important to show the state of an in- 
dividual's mind at the time certain acts are alleged to have 
been done. 

Shelf ord ' defines a lucid interval as "not a remission of 
the complaint, but a temporary and total cessation of it, and 
complete restoration to the perfect enjoyment of reason upon 
every subject upon which the mind was previously cogni- 
zant" ; and he adds : "The determination as to the existence 
of a lucid interval requires attentive observation and long and 
repeated examination by a person acquainted with the sub- 
ject of the patient's insanity." 

Taylor 3 says, with apparently less decision: "By a lucid 
interval we are to understand, in a legal sense, a temporary 
cessation of the insanity, or a perfect restoration to reason. 
This state differs entirely from a remission in which there is 
a mere abatement of the symptoms. It has been said that 
a lucid interval is only a more perfect remission, and that 
although a lunatic may act rationally and talk coherently, 
yet his brain is in an excitable state, and he labors under a 
greater disposition to a fresh attack of insanity than one 
whose mind has never been affected. Of this there can be 
no doubt, but the same reasoning would tend to show that 
insanity is never cured, for the predisposition to an attack is 
undoubtedly greater in a recovered lunatic than in one who 
is and has always been perfectly sane. Even admitting the 
correctness of this reasoning, it cannot be denied that luna- 
tics do occasionally recover, for a longer or shorter period, to 
such a degree as to render them perfectly conscious of and 
legally responsible for their actions with other people." 

All this is very true, but a cure is a very different thing 
from a lucid interval, for the latter, properly speaking, if it 

'"A Practical Treatise on the Law concerning Lunatics, Idiots, and Persons 
of Unsound Mind," London, 1833, p. Ixx. 

2 " The Principles and Practice of Medical Jurisprudence," vol. ii, second edi- 
tion, London, 1873, p. 484. 



DEFINITIONS AND DESCRIPTIONS. 281 

exists at all, must be a part of the disease, during which 
the tendency to a return is present to such a degree that the 
paroxysms will almost certainly recur. A complete restoration 
to mental health may be followed by a recurrence of the in- 
sanity, but then the period of cessation is scarcely a lucid 
interval in the true sense of the term, and the return should 
be regarded as a fresh attack. If the period during which 
an individual is entirely well, and extending, as it may, over 
several years, is to be regarded as a lucid interval, nearly 
every kind of insanity exhibits it. 

A patient, for instance, surfers with an attack of acute 
mania for several months, is restored to health, goes about 
his business, and attends to it as well as he ever did, perhaps 
marries, and has children. Undoubtedly a predisposition to 
another attack exists, but this may never be excited into ac- 
tion, and the person is regarded by every one as permanently 
cured. But, on the other hand, the tendency may, through 
some sufficiently exciting cause, be roused into activity, and 
another paroxysm, after many years of perfect health, mental 
and physical, be developed. Is it not stretching the point a 
good deal to call this period a lucid interval? Dr. Taylor, 
while avoiding the Scylla of remission, runs foul of the Cha- 
rybdis of cure. 

The case of Cartwright vs. Cartwright was adjudicated 
upon the presumption that the patient, a lunatic, had a lucid 
interval when she wrote her will. The testatrix had for some 
time been, as all acknowledged, insane. There were no collat- 
eral circumstances to indicate the existence of a lucid inter- 
val. She was in restraint at the time she made her will, and 
her hands were unbound so that she could hold a pen. She 
was alone when she performed the act, though observed 
through an aperture by persons in an adjoining room, who 
deposed that, while engaged in doing it, she frequently left off 
wilting, threw the pieces of paper into the fire, and walked 
about the room in a disordered manner. But the paper itself 
had no mark of irritation. Whatever outward appearance of 
disorder there may have been, it had no effect upon the writ- 
ing itself, which was a perfectly steady and correct perform- 
ance, entirely consistent with her attachments, impressions, 
and habits when in a sane condition, and written without a 
single mistake or blot. The will was planned and completed 
by the testatrix without any assistance, and afterward recog- 



282 DESCRIPTION AND TREATMENT OF INSANITY. 

nized by lier. ' Sir William Wynne, in deciding in favor of 
the will, said : "The strongest and best proof that can arise 
as to a lucid interval is that which arises from the act itself, 
which is the thing to be first examined, and, if it can be 
proved and established that it is a rational act rationally 
done, that is sufficient." But, if the performance of " a ra- 
tional act in a rational manner" is sufficient to establish the 
existence of complete sanity — for that is what a lucid inter- 
val is — nearly every lunatic is sane. To go to the fire for 
warmth, to put butter on bread, to wash clothes, to dig in 
the garden, to make baskets, are "rational acts rationally 
done," but they do not establish the existence of complete 
sanity. For this purpose, not only a single act or a dozen acts 
must be "rational and done rationally," but all the acts must 
come under this category. The idea that during a paroxysm 
of acute mania a person can be sane enough to make a valid 
will, the period of so-called lucidity lasting at most an hour, 
is simply absurd. Even a much longer duration of apparent 
sanity is frequently only a superficial glaze of rationality, 
which may be broken through by the slightest impression. 
A case which is of striking application to the point under 
notice is within my knowledge. A gentleman of this city be- 
came, during a period of great excitement, temporarily insane. 
After a not very long attack of acute mania, he was appar- 
ently restored to reason, and was about resuming his busi- 
ness, when he conceived the idea of making his will. He sent 
for his lawyer, and dictated clearly and fully all the provi- 
sions which he wished inserted in this document. His prop- 
erty was large, but he made such a disposition of it as his 
legal friend thought rational if not just. The will was signed, 
witnessed, and committed to the lawyer's hands for safe 
keeping. Soon afterward the gentleman had a relapse ; he 
recovered, however, and was finally pronounced cured. Two 
years afterward, meeting the lawyer in the street, he re- 
quested him to come to his house that evening, as he wished 
him to draw up his will. His friend asked him if he desired 
to cancel the will already made, and which he had in his safe. 
" I have never made a will," replied the gentleman. " Yes," 
answered the lawyer, "I drew one up for you more than two 
years ago ; you signed it ; it was witnessed, and is now in 
my safe." The gentleman was astonished. He had no recol- 

1 Shelford, op. &it. } p. 290. 



DEFINITIONS AND DESCRIPTIONS. 2S3 

lection of the matter, and, when the will was shown to him, 
he expressed the utmost surprise and regret at some of the 
provisions, which, as he said, were altogether different from 
those he would have made had he been of sane mind at the 
time. The will was destroyed, and a new one executed, dif- 
fering essentially from that which he had dictated during his 
so-called lucid interval. 

In a review of Redfield's "Law of Wills," 1 Dr. Isaac Ray 
makes some excellent remarks relative to the theory of lucid 
intervals, which, I think, fairly express the prevailing doctrine 
on the subject among the most intelligent physicians of the 
present day. He says : 

"No phenomenon of insanity has played a wider part in 
medical jurisprudence than lucid intervals, so called, and no 
one, we may also say, has been more differently understood. 
And the fact is not surprising, for they indicate a phase of 
the disease which none but those who have been long and in- 
timately connected with the insane can correctly appreciate. 
The descriptions of it in books serve to make the matter very 
clear, and leave the impression that lucid intervals are fre- 
quent occurrences, and easily distinguished from other re- 
missions of the disease ; and here lies the mischief, that of 
using a phenomenon which is complicated with many condi- 
tions not easily discernible for any important practical pur- 
pose. It is to be regretted that the phrase, implying as it 
does a foregone conclusion, ever found its way into the law. 
It certainly has led to mistakes, and will lead to many more 
before it ceases to influence the decisions of the courts. One 
author (Judge Redfield) inclines to believe that there is no 
essential difference between a lucid interval and a remission 
of the disease, and such we suppose to be the view generally 
entertained by those who are specially acquainted with the 
subject. The idea of a lucid interval being a temporary cure 
is now confined, we apprehend, to the writings of those whose 
notions of the disease have been derived from books rather 
than from the wards of a hospital. Like most other dis- 
eases, insanity is subject to remissions more or less complete, 
and there is no more propriety in regarding them as recov- 
eries than there would be in considering the intervals between 
the paroxysms of a quotidian fever as a temporary recovery. 
And, if the disease remained in any condition whatever, it is 

1 American Journal of Insanity, April, 1865, p. 515. 



28± DESCRIPTION AND TREATMENT OF INSANITY. 

mere presumption to say that the operations of the mind are 
entirely beyond its influence. This effect may not be very 
obvious, but the fact of its possible existence should render 
us cautious how we regard the acts of the insane during a 
lucid interval. In criminal cases the occasion will seldom 
arise, but in the matter of wills and contracts the decision 
will often depend on the speculative views that prevail on the 
subject." 

It is thus seen that Dr. Ray doubts the existence of lucid 
intervals in the sense in which they are commonly understood 
by lawyers, and as defined in the beginning of this descrip- 
tion. 

Relative to the subject, Dr. George Combe 1 says: "But, 
however calm and rational the patient may be during the 
lucid intervals, as they are called, and while enjoying the 
quietude of domestic society or the limited range of a well- 
regulated asylum, it must never be supposed that he is in as 
perfect possession of his senses as if he had never been ill. In 
ordinary circumstances and under ordinary excitement, his 
perceptions may be accurate and his judgment perfectly sound, 
but a degree of irritability remains behind which renders him 
unable to withstand any unusual emotion, any sudden provo- 
cation, or any unexpected or pressing emergency. Were not 
this the case, it is manifest that he would not be more liable 
to a fresh paroxysm than if he had never been attacked, and 
the opposite is notoriously the fact ; for relapses are always 
to be dreaded, not only after a lucid interval, but even after 
perfect recovery ; and it is but just, as well as proper, to keep 
this in mind, as it has too often happened that the lunatic has 
been visited with the heaviest responsibility for acts com- 
mitted during such an interval which previous to the first at- 
tack of the disease he would have shrunk from with horror." 

Dagonet 2 declares that " the lucid interval is no more 
health than the intermission between the attacks of ague is a 
cure. However much restored the reason may apparently be, 
the individual is placed in a special situation which the least 
circumstance may easily and instantaneously transform into 
one of disease. Doubtless the distinction is often difficult to 
establish ; it belongs to the physician, and, above all, to the 

1 " Observations on Mental Derangement,"' Edinburgh, 1831, p. 221. 
2 "Nouveau traite elementaire et pratique des maladies mentales," Paris, 
1876, p. 111. 



CLASSIFICATION. 285 

physician who has devoted himself to the study of insanity, 
to fix the character after an attentive examination in certain 
special cases. Tims, it is not rare to observe, in the asylums 
for the insane, some patients, in the moments of remission in 
their affections, show themselves to be calm and rational to 
such a degree that it would be difficult to prove that they 
were at all in an insane condition. If, however, they were 
in any way to be subjected to the excitements of life, they 
would immediately return to their state of intellectual de- 
rangement." 

There is a great deal more that might doubtless be ad- 
duced relative to lucid intervals, were it not for the fact that 
the subject in most of its relations appertains to the domain 
of medical jurisprudence. Enough has, however, been said to 
show that full, complete intervals in the course of an attack of 
insanity, during which the individual is well, and would so 
be pronounced by competent observers, are exceedingly rare. 
They are only to be found, in my opinion, in recurrent mania 
and the other forms previously mentioned. Remissions are 
common enough, but a remission is not a restoration to health, 
and the patient in whom it is exhibited ought not to be re- 
garded as being possessed of legal responsibility. 



CHAPTER II. 

CLASSIFICATION. 

The systems of classification of the several forms of in- 
sanity are almost as numerous as the writers on mental alien- 
ation. To detail at length the various arrangements which 
have been proposed would be of little service to the student, 
and, indeed, would mostly only confuse his mind. It will be 
sufficient to indicate the principles upon which some of the 
more important have been constructed, and to specify more 
minutely a few of those which appear to be of most impor- 
tance. 

There are six different methods which may be employed 
in the classification of mental diseases : 

1. The Anatomical, in which the forms are classified ac- 
cording to the part of the brain affected. 



286 DESCRIPTION" AND TREATMENT OF INSANITY. 

This is the method which is to be preferred to all others, 
but, unfortunately, our knowledge is not yet sufficient to en- 
able us to adopt it to any considerable extent. 

2. The Physiological, in which an attempt is made to clas- 
sify mental diseases according to the part of the encephalon 
involved, as determined by our knowledge' of its functions. 

The objection to this method, which has been proposed by 
Professor Laycock, 1 of Edinburgh, is similar to that urged 
against the anatomical method — lack of sufficient knowledge 
to enable us to make one that would be much more than 
guess-work. 

3. Tlie Etiological. — In this system the different forms of 
insanity are arranged according to the supposed causes. 
Morel 2 and Skae 3 have proposed elaborate schemes of classifi- 
cation in accordance with this method. Thus, we have the 
toxic insanity, such as is caused by alcohol, malaria, ergot, 
mercury, etc. ; hysterical insanity, epileptic insanity, etc., of 
Morel ; and the amenorrhceal mania, post-connubial mania, 
ovario mania, traumatic mania, and even the mania of oxal- 
uria and phosphaturia of Skae. 

4. The Psychological. — A classification from a psychologi- 
cal stand-point is one in which the pathology of the mind is 
arranged in accordance with the several categories of mental 
faculties. Hence, there is a perceptional, an intellectual, an 
emotional, and a volitional insanity, corresponding to the four 
divisions of the mind. There are some advantages belonging 
to this system, but there are disadvantages which more than 
overbalance them. It has been followed, in whole or in part, 
by many authors, among them being Crichton, 4 Arnold, 6 Hoff- 
bauer, 6 Heiiroth, 7 Griesinger, 8 and Despine. 9 It was the one 

1 " Mind and Brain," etc., Edinburgh, 18G9. 

2 " Traite des maladies men tales," Paris, 1860. 

3 Journal of Mental Science, 1863 and 1873. 

4 " An Inquiry into the Nature and Origin of Mental Derangement," etc., 
London, 1798. 

6 " Observations on the Nature, Kinds, Causes, and Prevention of Insanity," 
second edition, London, 1806. 

6 " Untersuchungen iiber die Krankheiten der Seele," Halle, 1802, 5-7. 

7 " Lehrbuch der Storungen des Seelensbebens," Leipzig, 1818. 

8 "Die Pathologie und Therapie der psychischen Krankheiten," Stuttgart, 
1863, 2te Auflage. 

9 " De la folie du point de vue philosophique ou plus specialment psycholo- 
gique." Paris, 1875. 



CLASSIFICATION. 237 

which was adopted in the earlier editions of my "Treatise on 
the Diseases of the Nervous System." in which insanity was 
considered. Mature reflection has, however, convinced me 
that it cannot be exclusively followed, although it may very 
properly be the basis for a satisfactory classification — satisfac- 
tory, that is, in the present state of pur knowledge of brain 
anatomy, physiology, and pathology. 

5. The Pathological. — In this method of arrangement the 
various forms of insanity are classified according to the mor- 
bid conditions of the brain, which are supposed to be in im- 
mediate relation with them as causes and effects. This basis 
is that adopted by Luys ' in his recent work on insanity, who 
divides all forms of mental derangement into three classes — 
those which result from cerebral hyperemia, those due to 
cerebral anaemia, and those in which both conditions exist 
simultaneously in different parts of the brain. 

It was still more elaborately laid out by M. Aug. Voisin, 2 
who, in addition to the recognition of congestion and ansemia 
as pathological states acting as the immediate causes of in- 
sanity, designated also atheroma of the cerebral arteries and 
tumors of various parts of the encephalon as giving rise to 
mental derangement. 

According to M. Aug. Voison, all insanity may be divided 
into six classes : s 

"1. Acquired Insanity. — That which supervenes in the 
course of the life of the individual, and which has been pre- 
ceded by a state of ordinary intelligence. 

"2. Native Insanity. — That in which the intellectual 
troubles are shown at an early age, especially under the influ- 
ence of heredity. 

"3. Insanity by intoxication, or virus, the nature of 
which is indicated by its name. 

"4. Cretinism, idiocy, and imbecility, under which head 
are embraced a great number of forms of mental derange- 
ment, characterized either by a weakness of the will and the 
understanding, giving rise to feebleness of mind to the extent, 
perhaps, of an almost complete abolition of the mental facul- 
ties, with or without lesions of the skeleton. 

"5. General Paralysis.— The best studied form of insan- 

1 " Trait6 clinique et pratique des maladies mentales," Paris, 1881. 

2 " Lemons cliniqnes sur les maladies mentales," Paris, 1876. 

3 Op. cit., p. 15. 



28S DESCRIPTION AND TREATMENT OF INSANITY. 

ity — one in which the lesions and the symptoms have been 
placed intimately in relation with each other, and with our 
actual knowledge of the physiology of the nervous system. 

"6. Senile Dementia" 

The class of acquired insanity embraces primitive or idio- 
pathic insanity, secondary insanity, sensorial insanity, 
and sympathetic insanity. 

The essential part, however, of M. Aug. Yoisin's classifi- 
cation is that any variety of insanity may be due to conges- 
tion, anaemia, atheroma, or tumors, and the condition, which- 
ever it may be, determines the character of the symptoms of 
any one variety. Thus, a case of primitive insanity belonging 
to his first class may be due either to congestion or to anaemia 
of the brain. If the former, the type will be one of mental 
exaltation ; if the latter, of mental depression. He is, how- 
ever, obliged to admit that it may be the result of inappreci- 
able lesions ; that is, without congestion, anaemia, atheroma, 
or tumors being present. The same may be said of his other 
forms ; so that while the classification is ingenious, and is a 
good basis for further investigation, it cannot be accepted as 
a finality, or as . tending to simplify the study of the subject 
of mental derangement. 

6. The Clinical or Symptomatological Classifications, 
based on the clinical features or symptoms exhibited by the 
varieties of insanity, are those which are most in vogue at the 
present time. As insanity as a whole is only a symptom of 
brain disease, it follows that such classifications are merely 
arrangements of the phenomena or symptoms into groups for 
study, investigation, and treatment. Perhaps, notwithstand- 
ing this fact, such systems, in some form or other, are about 
the best which are attainable in the present state of our 
knowledge. A very simple grouping is that of Leidesdorf ' 
and other writers — namely, states of mental depression, 
states of mental excitement, states of mental weakness. 
Under the first head are embraced all the forms of melan- 
choly ; under the second, mania in general and monomania 
in particular ; under the third, imbecility, dementia, and 
idiocy. 

One of the most recent classifications is that of Kraft Eb- 
ing. a On account of the recognized position of its author, as 

1 "Lebrbuch der psychischen Krankbeiten," Erlangen, 1865. 
a " Lebrbuch der Psycbiatrie," u. s. w., Stuttgart, 1880. 



CLASSIFICATION. 289 

also of the fact that it is put forth as representing the present 
state of psychological medicine, I give it entire : 

A. Psychical Diseases of the Fully Developed Brain. 

I. THE PSYCHO-NEUEOSES. 

1. Primary Curable Conditions. 

a. Melancholia. 

aa. Melancholia passiva. 
bb. Melancholia attonita. 

b. Mania. 

aa. Maniacal exaltation. 
bb. Acute mania (Tobsucht). 

c. Primary dementia (Stupiditat). 

2. Secondary Incurable Conditions. 

a. Chronic mania (seconder Verrucktheit). 

b. Terminal dementia. 

aa. Dementia with excitement. 
bb. Dementia with depression. 

II. PSYCHICAL DEGETTEEATIONS. 

a. Constitutional affective insanity (folie raisonnante). 

b. Moral insanity. 

c. Primary mania. 

aa. With delusions of persecution. 

bb. With exaltation (erotic and religious mania). 

cc. Imperative conceptions (morbid impulses ?). 

d. Insanity from constitutional neuroses. 

aa. Epileptic insanity. 

bb. Hysterical insanity. 

cc. Hypochondriacal insanity. 

dd. Periodical insanity. 

III. BEAIN DISEASES WITH PEEDOMINATING PSYCHICAL DIS- 

TUEBANCES. 

a. Dementia paralytica. 

b. Cerebral syphilis. 

c. Chronic alcoholism. 

d. Senile dementia. 

e. Acute delirium. 



19 



290 DESCRIPTION AND TREATMENT OF INSANITY. 

B. Psychical States of Arrested Development, Idiocy, 

and Cretinism. 

The objections to this arrangement are mainly that it is 
too full in some respects and too meagre in others. In fact, it 
is not consistent with the principles upon -which it is founded. 
Thus, while moral insanity is recognized, there is no mention 
of that form of mental derangement in which there is an ina- 
bility to exert the will. If alcoholic insanity is introduced 
into psychological nosology, why should absinthine insanity 
be left out ? There is no mention of puerperal insanity, cir- 
cular insanity, hebephrenia, and other well-known forms. 
Moreover, the system is radically imperfect which makes 
classes of conditions depend for their arrangement on their 
presumed curability or incurability. 

Far better is the simpler arrangement proposed by Dr. 
Spitzka, 1 in which, while there is no attempt at a systematic 
classification into groups or genera, the several forms which 
he recognizes are enumerated in an order which is itself not a 
necessary feature. It is as follows : 

1. Progressive paresis. 

2. Senile dementia. 

3. Chronic confusion of ideas. Chronic mania proper. 

4. Chronic mania with imbecility. 

5. Monomania. 

6. Hebephrenia. 

7. Katatonia. 

8. Circular insanity. 

9. Epileptic insanity. 

10. Periodical insanity. 

11. Acute mania. 

12. Lypemania. 

So far as it goes, no classification could be better than this, 
but the objections to it are that it does not embrace all known 
forms of insanity, and that the psychological element is not 
recognized. Perhaps its extension in its present line would 
be amply sufficient for purposes of study and practical appli- 
cation, but as a treatise on insanity should be something more 
than a mere manual of practice, so a system of classification 
upon which the treatise is based should also be more. It 

1 " On the Scientific Necessity for a Clinical Demarkation of the Various 
Forms of Insanity," Medical Gazette, May 15 and 29, 1880. 



CLASSIFICATION. 291 

should not only, as far as practicable, embrace all well-estab- 
lished varieties of mental alienation, but it should, at least, 
make the attempt to arrange them in groups, according to 
whatever philosophical idea may exist in the mind of its au- 
thor. The system adopted may be wrong, it may be artificial 
and strained, it may lack exactness and sharpness in its boun- 
daries ; but, nevertheless, it is better than none, and will at 
least, by exciting thought in the mind of the reader, lead to 
discussion, and, perhaps, a better system. 

Influenced by these ideas, I venture to propose the follow- 
ing arrangement. It is not claimed that it is perfect ; it is not 
asserted that the several groups are in all cases clearly sepa- 
rated from each other ; on the contrary, I know very well that 
they are not. There are, perhaps, for instance, few if any of 
the forms which I have classed under the head of "Intellect- 
ual Insanities" which do not show emotional disturbance 
also. I have placed them where they are for the reason that 
the chief manifestations of mental disorder which they ex- 
hibit relate to the intellect. It may be true that not a single 
one of the forms which are designated as ' ' Emotional Insani- 
ties" are not constantly marked by intellectual derangement, 
but I do contend that their most prominent characteristics are 
connected with the emotions, and I have classified them in 
accordance with that view. Similar remarks are applicable 
to the varieties which I have placed under the head of " Voli- 
tional Insanities," though not to the same extent. 

The division of "Compound Insanities" embraces those 
forms which are either so constituted that no predominance of 
intellectual, emotional, or volitional derangement can be de- 
termined, or which manifest themselves in these respects dif- 
ferently with different individuals. 

The group of "Constitutional Insanities" comprises those 
varieties which are either the result of some pre-existing 
physiological or pathological condition, or which owe their 
origin to a general toxic state of the system. 

Under the head of "Arrest of Mental Development" are 
placed those states which are due to deficient brain and ner- 
vous development. 

Eelative to the first-named group, " Perceptional Insanities," 
I have to say that as the perceptions in health form the basis 
of all higher mental processes, so in mental jderangement they 
are the groundwork on which most of the various forms of 



292 DESCRIPTION AND TREATMENT OF INSANITY. 

insanity are constructed. That they may be the seat of dis- 
order without the other categories of mental faculties being 
affected admits of no doubt, and there is hence no good reason 
why their aberrations should not be included in a classifica- 
tion intended to embrace all well-established forms of mental 
derangement. 

I have not placed such forms as alcoholic mania, malarial 
mania, absinthine mania, podagral mania, and many others of 
the kind in this classification, for I do not believe that the 
cause in such cases exercises any influence as a modificator of 
the type. Malarial mania, for instance, is not distinguishable, 
so far as the symptoms are concerned, from the mania pro- 
duced by alcohol. Moreover, of several cases, for instance, of 
malarial mania, and many of alcoholic mania, which have come 
under my observation, some were characterized by mental 
exaltation, others by mental depression, and others again 
were well-marked instances of primary dementia. Alcohol, 
malaria, gout, rheumatism, etc., act as causes, but do not 
give rise to specific types of insanity. 

I. Perceptional Insanities. — Insanities in which there are de- 
rangements of one or more of the perceptions. 

a. Illusions. 

5. Hallucinations. 

II. Intellectual Insanities. — Forms in which the chief mani- 
festations of mental disorder relate to the intellect, being of 
the nature of false conceptions (delusions), or clearly abnormal 
conceptions. 

a. Intellectual monomania with exaltation. 
5. Intellectual monomania with depression. 

c. Chronic intellectual mania. 

d. Reasoning mania. 

e. Intellectual subjective morbid impulses. 
/. Intellectual objective morbid impulses. 

III. Emotional Insanities. — Forms in which the mental de- 
rangement is chiefly exhibited with regard to the emo- 
tions. 

a. Emotional monomania. 

b. Emotional morbid impulses. 

c. Simple melancholia. 

d. Melancholia with delirium. 

e. Melancholia with stupor. 

f. Hypochondriacal mania, or melancholia. 



CLASSIFICATION. 293 

g. Hysterical mania. 

h. Epidemic insanity. 

IY. Volitional Insanities. — Forms characterized by derange- 
ment of the will, either by its abnormal predominance or 
inertia. 

a. Volitional morbid impulses. 

b. Aboulomania (paralysis of the will). 

V. Compound Insanities. — Forms in which two or more cate- 
gories of mental faculties are markedly involved. 

a. Acute mania. 

b. Periodical insanity. 

c. Hebephrenia. 

d. Circular insanity. 

e. Katatonia. 

f. Primary dementia. 

g. Secondary dementia. 
Ti. Senile dementia. 

i. General paralysis. 

VI. Constitutional Insanities. — Forms which are the result of 
a pre-existing physiological or pathological condition, or of 
some specific morbid influence affecting the system. 

a. Epileptic insanity. 

b. Puerperal insanity. 

c. Pellagrous insanity. 

d. Choreic insanity, etc. 

VII. Arrest of Mental Development. 

a. Idiocy. 

b. Cretinism. 

As each particular form is brought under consideration, 
the subdivisions of which it is capable will be indicated. This 
course is not followed now, in order to avoid any possible 
confusion which might arise from the necessarily intricate 
construction of the table. 

Although arrests of mental development are necessary to 
be considered in the classification of the several forms of de- 
rangement of the mind, it is not the intention to discuss them 
in the present treatise. The treatment which they require is 
quite special, and it is such as is not within the province of 
the medical practitioner, unless he gives himself up to the 
work and to that alone. 



294 DESCRIPTION AND TREATMENT OF INSANITY. 

CHAPTER III. 
i. 

PERCEPTIONAL INSANITIES. 

In uncomplicated perceptional insanities those parts only 
of the brain are disordered which are concerned in the forma- 
tion of perceptions. They constitute the primary form of 
mental aberration, and of themselves are not of such a char- 
acter as to lessen the responsibility of the individual or to 
warrant any interference with his rights. They consist en- 
tirely of false perceptions ; and if the intellect should be for 
a moment deceived, the error is immediately corrected. As 
already stated, there are two forms of false perceptions — illu- 
sions and hallucinations. In some cases they coexist in the 
same individual. They may be related to any one or more of 
the special senses, but are especially common as regards sight 
and hearing. 

a— ILLUSIONS. 

Illusions, as already mentioned, are not necessarily due to 
any central disturbance, though such an origin is common. 
It is, of course, only when they have such an origin that they 
are an indication of mental derangement. Thus, it is an illu- 
sion if a person, on looking at one object, sees two images, or 
if, when a single sound strikes the ears, he hears two sounds, 
and often pitched on different keys. In the first case, the re- 
sult is due to some cause destroying the parallelism of the 
visual axes, and may be produced by a tumor of the orbit or 
by paralysis of one or the other of the ocular muscles. In 
the latter, it is caused by disease of the middle ear, producing 
a different degree of pressure upon the fluid in the labyrinth 
of each ear. A gentleman who has this symptom informs 
me that at first it was difficult for him to avoid the belief that 
two persons were talking to him at the same time and saying 
the same thing, one being a little slower than the other in his 
speech, and having a voice pitched in a slightly lower key. 

Illusions may also result from a combination of circum- 
stances unfavorable to perfect sensation. Thus, when the light 
is insufficient there may be illusions of the sense of sight. 
This is especially apt to be the case in the mystifying light of 
the moon, in which objects are more or less disturbed from 



PERCEPTIONAL INSANITIES. 295 

their natural appearance. Under such a condition a roadside 
bush may appear to be an animal of some kind or other, and 
a guide-post look like a man on horseback. The state of mind 
of the individual has great influence in modifying the images 
which form on the retina, the words which reach the tympa- 
num, the odors which impinge on the Schneiderian membrane, 
the flavors which touch the tongue, or the objects which come 
in contact with the tips of the fingers, and this strictly within 
the limits of health. It is well known that many people, for 
instance, can see what they wish to see. Falret cites a story, 
from Fontenelle's " Pluralite des Mondes," of a priest and a 
young lady talking together in the light of the moon, and ex- 
amining the lights and shadows on the face of that luminary. 
" Do they not look to you like cloisters ? " said the clergyman. 
" Oh, no," she answered, " not in the least; I should rather 
say like two lovers." 

But illusions such as these, and many others that might 
be mentioned, do not now require consideration. We have 
rather to give attention to those which, resulting from central 
derangement, belong to the domain of mental pathology. 

Illusions of this character, without the implication of the 
higher categories of mental faculties, are rare. Still, there is 
no doubt that they do exist. That is, that there are illusions 
not the results of derangement of the organs of sense, or of 
circumstances unfavorable to exact perception, but which are 
due to a morbid condition of the perceptional ganglia, and 
the unreal nature of which is clearly recognized by the indi- 
vidual. 

Illusions of sight often relate merely to the size of objects. 
Thus, a young lady who had overtasked herself at school saw 
everything of enormous size at which she looked. The head 
of a person seemed to be several feet in diameter, and little 
children looked like giants. When I took out my watch, 
while examining her pulse, she remarked that it was as large 
as the wheel of a carriage. The room in which she sat ap- 
peared to her to be several acres in extent. So far as her own 
person was concerned there were no illusions. Her own hands 
appeared of the natural size, but, as soon as she turned her 
eyes to the hands of other people, she at once saw those of 
enormous proportions. Saurages refers to a somewhat similar 
case, in which a young woman suffering from epilepsy had the 
illusion of seeing objects greatly magnified in size. A fly 



296 DESCRIPTION AND TREATMENT OF INSANITY. 

seemed to her to be as large as a chicken, and a chicken ap- 
peared to be as big as an ox. In the case which came nnder 
my observation, the nnreal character of the perception was 
fully recognized, and hence the intellect was not involved. 

A gentleman who had met with severe pecuniary losses, 
and who had consequently endured great anxiety and dis- 
tress, consulted me for an illusion of the sense of sight witlr 
which he was troubled every night as he was about going to 
bed. The banister-post — technically called a newel-post — at 
the head of the stairs was large, and, notwithstanding the 
fact that the hall was well lighted, this post always appeared 
to him like a very tall and thin woman, who stood leering at 
him with a diabolical expression of countenance. The mo- 
ment he touched the post the illusion ceased, but until then, 
from the time he came within sight of the object, it persisted. 
His only way to escape from it was to shut his eyes and to 
keep them closed till he had passed it. If he kept them open, 
he felt impelled by a force he could not resist to turn them 
toward the post, and then instantly it assumed the form of 
the tall and thin woman. At any time after dining, if he 
went upstairs, he had the illusion as soon as he came within 
sight of the post, but a night' s rest, or even a little sleep, 
seemed to have the power of dispelling it, or at least gener- 
ally so, for he rarely saw it on his way down stairs in the 
morning. Upon one occasion he sat down, and, fixing his eyes 
on the post, resolved that he would, if possible, tire out his 
adversary, but the longer he looked the more distinct she be- 
came, until after three or four minutes his head began to ache 
violently, and he gave up the attempt. The next morning his 
head was still painful, and then, as he passed by on his way 
down stairs, he had the illusion. With this evidence of intra- 
cranial derangement there were others which clearly pointed 
to cerebral hypersemia, to which condition the illusion was 
doubtless due. His intellect did not for a moment accept the 
false perception as real. 

In another case the patient, a lawyer of a neighboring city, 
was so subject to illusions of the sense of sight that he found 
it very difficult to determine the true from the false images 
which he perceived, and, as a consequence, he made many mis- 
takes. He would often take a stranger for an intimate friend, 
and address him as such, and again would pass his acquaint- 
ances, and even his relatives, without recognizing them. If 



PERCEPTIONAL INSANITIES. 297 

one of the latter would say, " Why, J., don't yon know me ? " 
he wonld stop, look his questioner in the face, and answer, 
" So far as I know, I never saw you before, but I'll take your 
word for it ; who are you ? " And, when told, would say, " All 
right ! 1 suppose you are ; but you don't look like any one I 
ever knew." This gentleman had also great difficulty occa- 
sionally in estimating distances by the eye ; but this he was 
able to correct by his judgment. 

St. Theresa states that she often saw the wooden cross of 
her rosary changed into another cross composed of four pre- 
cious stones of supernatural beauty. 

Illusions of hearing, due to derangement of the percep- 
tional ganglia, but unaccompanied by derangement of the in- 
tellect, are not very common. One case only has come under 
my observation, but this was a very interesting one. It was 
that of a gentleman to whom the ticking of a clock on the 
mantle-piece was resolved into articulate words. At first he 
only had this illusion at night after he went to bed, but after 
a few weeks the ticking of any clock sounded to him like 
human speech. There was no uniformity either of the tone 
or of the language employed, but sometimes a particular 
phrase would be repeated hundreds of times. As soon as he 
got beyond the range of the sound from the clock, the words 
were no longer heard. 

Generally the expressions were in the form of commands. 
For instance, if at dinner, they would be, "Eat no soup!" 
" Drink no wine!" or, "Eat your soup!" "Drink some 
wine ! " and so on. One day he made the discovery that, if he 
closed the right ear firmly, the illusion disappeared ; but, if 
the left ear were closed, the words were still distinctly heard. 
It was hence clear that the centre for hearing on the right 
side was the one affected, and that that on the left side was 
normal. On neither side was there the slightest impairment 
of the capacity for hearing other sounds. A watch could be 
readily heard to tick at the distance of three feet from either 
ear. 

For a long time this gentleman resisted accepting any of 
these illusions as facts, but after a time he began to be influ- 
enced by them to the extent of regarding them as guides, 
though he tried to conceal the circumstance. When asked, 
for instance, whether or not he was going to the theatre that 
evening, he would reply, in a nonchalant way, to the effect 



29S DESCRIPTION AND TREATMENT OF INSANITY. 

that lie had not thought about it, and then, after a little 
while, when he thought the matter forgotten, he would saun- 
ter toward where the clock stood, and shortly afterward give 
his answer, either affirmatively or negatively, according to the 
words conveyed to him by the clock. Eventually he put 
clocks in every room in his house, and -professed to be gov- 
erned altogether by the directions they gave him. Not, as 
he said, from any belief that the ticks were real words, but be- 
cause there was probably some influence, spiritual or other, 
that caused them to seem like words to him. 

Illusions of touch, as Michea 1 says, may relate to tem- 
perature, movement, weight, and the character of surfaces. 
Thus, to some patients, substances that are hot feel cold, and 
vice versa; others feel the things on which they sit or lie 
glide from under them. 

Cabanis a states that a man who had an abscess of the cor- 
pus callosum several times told him that during the course of 
his disease he felt his bed sink away from his body. Illu- 
sions in regard to temperature and weight are common with 
the subjects of locomotor ataxia, but in these cases the lesion 
is in the spinal cord. There is, however, reason for think- 
ing that the cord is to some extent a centre for perceptions 
of touch. 

Various abnormal sensations existing on the surface of the 
body become illusions with some persons. Thus, one feels a 
tight band encircling the head, another has a sensation such 
as would be produced by the claw of a bird scratching the 
vertex, and another as if a fly were crawling over the face. 

Illusions connected with the internal viscera, and analo- 
gous to those of external touch, are quite common, especially 
with hypochondriacs ; and again they may be of a general 
character as regards the whole body — giving the sensation of 
extreme weight or lightness — or as if the body were im- 
mensely lengthened or shortened. 

The sensation of lightness has induced some hyperses- 
thetic or hysterical persons to believe that they have actu- 
ally been raised from the ground. St. Theresa 3 frequently 

1 "Des hallucinations," etc., "Memoires de l'academieroyale demedecine," t. 
xii, p. 252. 

2 "Rapports du physique etdu moral de l'homme," Paris, 1824, t. i, p. 148. 

3 "The Lives of the Fathers, Martyrs, and other Principal Saints," London, 
S. A., vol. x, p. 385, et seq. 



PERCEPTIONAL INSANITIES. 299 

experienced this sensation. This remarkable woman was 
born in 1515. From a very early age she was afflicted with 
frequent fits of fainting and violent pain at her heart, which 
sometimes deprived her of her senses. Sharp pains were fre- 
quent through her whole frame, her sinews began to shrink 
up, and finally, in August, 1537, she fell into a lethargic coma 
or trance which lasted four days. At one time she was 
thought to be dead, and her grave was actually dug. During 
this attack she bit her tongue in several places, and was for a 
long time unable to swallow. Sometimes her whole body 
seemed as if her bones were disjointed in every part, and her 
head was in extreme disorder and pain. It is quite evident 
from all this that St. Theresa was a hystero-epileptic. 

Speaking of the elevation of her soul, she says that some- 
times her whole body was lifted up with it from the ground, 
though this was seldom, and that when she tried to resist the 
elevation there seemed to be a mighty force under her which 
raised her up in spite of all her efforts. Hundreds of such 
cases are given in the lives of the saints, and many of less 
holy personages. 

Madame d'Arnim, Goethe's friend, in speaking of the sen- 
sation in question as experienced by herself, says: "I was 
certain that I flew and floated in the air. By a simple elastic 
pressure of the toe, I was in the air. I floated silently and 
deliciously at two or three feet above the earth. I alighted, 
mounted again, flew from side to side, and then returned. A 
few days after, I was taken with fever, I went to bed and slept. 
It happened two weeks after I was confined." ' 

The following instances are within my own experience : 

A lady of strongly marked hysterical temperament and of 
most fanatical religious tendencies often had the sensation 
that she was raised from the ground while she was in the act 
of saying her prayers. She usually spent several hours each 
day in these exercises, and during the whole time was in a 
state of fervid exaltation, which rendered her insensible to all 
that was passing around her. While in this condition she 
would exclaim, " I rise ! I rise ! I see angels ! " and, with her 
hands raised on high, her head elevated, her face turned up- 
ward, and her countenance illuminated with ecstatic radiance, 
she really did seem to some superficial and sympathetic ob- 

1 " Correspondence de Goethe et de Bettina," translated by M. Sebast. Al- 
bin, t. i, p. 63. 



300 DESCRIPTION AKD TREATMENT OF INSANITY. 

servers to be lifted up. A young married lady, formerly 
under my professional care, was very confident that, during 
the cataleptic seizures to which she was subject, she was raised 
from her bed. In neither of these cases was there any per- 
manent deception of the intellect, and both eventually lost 
their illusions. 

As Brierre de Boismont l remarks : " The sensation of fly- 
ing is rather common. Frequently in dreams we feel ourselves 
carried along with the rapidity of an arrow ; we accomplish 
great distances, just lightly touching the ground. We have 
noticed this fact in a literary man of our acquaintance whom 
we have several times found with fixed eyes, and who said to 
us, ' I am flying, do not stop me.' On returning to himself, 
he described his sensations, and it seemed to him that he 
really had flown." 

The sensation of amplification of the body is also an occa- 
sional illusion. Thus, Gorres 2 states that the blessed Ida of 
Lorraine, who lived in the convent of Rosenthal, was so filled 
with the desire to render herself acceptable to the Lord that 
one night, as she occupied a bed with a very devout nun, her 
intense longing so filled her soul that very soon all the mem- 
bers of her body began to swell, and quickly assumed mon- 
strous proportions. The skin of one of her legs burst, so 
great was the strain, and she ever afterward had the cicatrix. 
The poor nun, her bedfellow, did not know what to think of 
this enormous amplification of the saintly Ida, and her situ- 
ation in addition was rendered very uncomfortable, for the 
swelling saint went on enlarging till she occupied all but a 
very narrow strip of the bed. Suddenly, however, things 
changed. Ida's body diminished little by little, till at last it 
was reduced to an extremely minute size. This phenomenon 
was reproduced as she was returning from the church with 
her friend. 

In such a case, and in many others which have helped to 
enlarge the ranks of the credulous, the statements of the il- 
lusionated individuals are so strongly expressed that they 
serve to deceive many of those who hear them. Nothing is 
easier than to make others perceive things which they are em- 
phatically told they must perceive. 

1 " A History of Dreams, Visions, Apparitions, Ecstasy, Magnetism, and Som- 
nambulism," American edition, Philadelphia, 1855, p. 94. 

a " La mystique, divine, naturelle et diabolique," Paris, 1861, t. i, p. 349. 



PERCEPTIONAL INSANITIES. 3 01 

Illusions of taste and of smelly except with persons who 
are otherwise insane, are not common. No instance of an il- 
lusion of smell of the kind under notice has occurred within 
my personal experience ; several cases of illusions of taste 
are, however, within my knowledge. To one of these, a 
lady, everything she put into her mouth tasted like cauli- 
flower ; in another instance, the flavor was that of strong 
Roquefort cheese, and in another of pears. 

As regards frequency, illusions of the sense of touch oc- 
cupy the front rank ; next are those of sight, and next those 
of hearing. Illusions of smell and taste are less frequent 
than the others. 

Illusions as symptoms of higher forms of mental aliena- 
tion will engage our attention further on. * 

~b — HALLUCINATIONS. 

Bearing in mind what has been previously said, the student 
will have no difficulty in recognizing the difference which ex- 
ists between illusions and hallucinations, and will, therefore, 
recall the fact to his recollection that the latter are entirely 
cerebral in origin, and do not require, as do the former, a mate- 
rial basis. That they may and often do exist without the im- 
plication of the intellect is not a question in dispute at the 
present day. They cannot be produced by any defects or de- 
rangements of the sensory organs, or by any external circum- 
stances tending to interfere with the regular and normal ac- 
tions of these organs. When present, therefore, they are 
always an evidence of cerebral disorder. We have to consider 
them now as resulting from disorder of the perceptional gan- 
glia without the implication of those parts of the brain which 
are concerned in the production of intellect, emotion, or will. 

Beginning with the consideration of hallucinations of sight, 
the case of M. Andral, 1 the distinguished French physician, 
is interesting. "At the beginning of my medical studies," 
he says, " I was intensely interested in seeing, in a corner of 
the dissecting-room at La Pitie, the dead body of a child half 
devoured by worms. The following morning, on going to the 
fireplace to kindle my fire, I saw this corpse. It was distinctly 
before my vision, and I even smelled its putrid odor, although 
all the time I kept telling myself that the thing was impossi- 
ble. This hallucination lasted about a quarter of an hour." 

1 " Cours de patliologie interne," t. iii, p. 184. 



302 DESCRIPTION AND TREATMENT OF INSANITY. 

Here there was nothing to show the implication of the in- 
tellect. The false appearance was not even for an instant ac- 
cepted as a reality. Its origin was clearly in the brain, and 
was a projection of an impression made npon it the previous 
day in the dissecting-room. 

The case of Mcolai, the German bookseller, is another 
striking instance of the existence of hallucinations of sight 
without intellectual disturbance. 

During the ten latter months of the year 1790 he had been 
the subject of a good deal of emotional disturbance in conse- 
quence of the supervention of several melancholy incidents. 
A customary bloodletting was omitted, and added to all was 
an unusual press of business matters, and a sharp altercation 
which took place' on the morning of the day on which the 
hallucinations supervened. Suddenly he perceived, at appa- 
rently the distance of ten steps, a form like that of a deceased 
person. He pointed at it, asking his wife if she did not see 
it. She saw nothing, but his question alarmed her so much 
that she sent for a physician. The phantom continued for 
about ten minutes. In a short time he grew more calm, and 
fell asleep. But at four in the afternoon the form he had 
seen in the morning reappeared. He arose and went to an- 
other room, the apparition accompanying him, disappearing, 
however, at intervals, and always maintaining the erect pos- 
ture. At about six o'clock there appeared other figures unlike 
the first. 

After the first day the figure of the deceased person no 
longer appeared, but its place was supplied by many other 
phantoms, sometimes representing acquaintances, but mostly 
strangers. They seemed to be equally clear and distinct at 
all times and under all circumstances, both when he was alone 
and in company, and as well in the day as at night, and in 
his own house as well as abroad. They were, however, less 
frequent when he was in the house of a friend, and rarely ap- 
peared to him in the street. When he shut his eyes these 
phantasms would sometimes vanish entirely, though there 
were instances when he beheld them with his eyes closed. 
When they disappeared from this cause, they generally re- 
turned when he opened his eyes. Generally he saw human 
forms of both sexes, but they usually did not appear to take 
the least notice of each other, moving as in a market-place, 
where all are eager to pass through the avenue ; at times, 



PERCEPTIONAL INSANITIES. 303 

however, they seemed to be transacting business with each 
other. He saw also, on several occasions, people on horseback, 
dogs, and birds. All these phantoms appeared to "him of 
their natural size, and as distinct as though alive, exhibiting 
different shades of carnation in the uncovered parts, as well 
as different colors and fashions in their dresses. Though the 
colors seemed somewhat paler than in real nature, none of the 
figures appeared particularly terrible, comical, or disgusting, 
most of them being of an indifferent shape, and some pre- 
senting a pleasing aspect. The longer these phantoms con- 
tinued to visit him, the more frequently did they return, while 
at the same time they increased in number. After about four 
weeks had elapsed he began to hear them talk. 

The application of leeches to the arms relieved him 
promptly of his hallucinations. 

Michea 1 cites from St. Gregory of Tours the case of a 
man of his time who was overwhelmed by an impulse to 
commit suicide. He made ready with a rope, but, not hav- 
ing quite determined on the act, he implored the assistance 
of the apostle St. Paul. He had no sooner uttered his in- 
vocation than he perceived before him a figure of sinister 
and diabolical aspect, who thus addressed him: "Courage; 
do not longer defer the execution of the resolution you have 
taken." The unfortunate man at once placed the rope around 
his neck, but, before he could execute his project, he saw 
another figure, which said to the other form: " Get out, 
wretch ! This man has called upon St. Paul for aid, and 
the great apostle has heard him ; he is here." At these 
words the two figures disappeared, and the man was relieved 
of his temptation. 

This story is given, not as being entitled to much credit — 
for it is supposed to refer to an event which took place over 
thirteen hundred years ago — but as an example which, having 
all the elements of probability about it, seems well adapted 
to illustrate the character of the hallucinations of a remote 
period. 

Pascal saw a cavern constantly yawning at his side, and, 
though it did not impose on his intellect, he felt more comfort- 
able with a screen so arranged that he could not see it. Other 
instances of hallucinations of sight existing with intellectual 
integrity are cited in the chapters on sleep and dreams. 
1 "Des hallucinations," op. cit., p. 253. 



304 DESCRIPTION AND TREATMENT OF INSANITY. 

I have had experience in my practice of many cases of 
like character. In one of these, a yonng lady of good men- 
tal development, but of delicate physical organization, was 
for several months almost constantly troubled with appari- 
tions of various kinds of faces, which she saw no matter 
where she turned her eyes. She had, while looking through 
her father's library a few weeks before they first appeared, 
come across a book containing many engravings of Roman 
and Grecian masks, and these had made a great impression 
on her. The false faces beset her on all sides. Sometimes 
they would peep at her from around the corners of the 
streets as she was driving or walking. Again she would see 
them coming out of the shelves in the shops she visited, and 
again they would start up from the street just before her. 
They never passed out of her range of vision suddenly, but 
gradually faded away without changing their positions. If 
she closed one eye she saw fewer, and if she shut both eyes 
at the same time, they disappeared altogether for a time. If, 
however, she kept the eyes closed for a few minutes, they re- 
appeared, but less distinctly, and, when she opened her eyes, 
this set vanished at once, and a new series came on the field. 
They were of all colors and nationalities, and a good many 
were of the same appearance as the grotesque masks of the 
ancients. She never saw them after dark except in well- 
lighted rooms or other places. The gas-light of the streets 
was not sufficient to develop them, but the electric light 
brought them out very distinctly. By repeating the experi- 
ment of Sir David Brewster — pressing on the outside of the 
globe of either eye so as to produce temporary strabismus — 
she could make any face appear double, but this was only 
when it had been visible for several minutes. A newly ap- 
pearing face she could not duplicate in this way. 

In another case, occurring in a young man who had re- 
ceived a severe blow on the head just above the left ear a few 
weeks previously, the hallucination consisted of a large black 
cat that followed him wherever he went, and sometimes 
jumped on his lap or his shoulder. He was clearly aware of 
the fact that the appearance was unreal, but it nevertheless 
gave him a good deal of annoyance. Being possessed of a 
considerable degree of intelligence, he had, by observation 
and experiment, settled several interesting points to his satis- 
faction. Thus, he found that the image was always larger 



PEECEPTIONAL INSANITIES. 305 

and more distinct in the evening than soon after getting ont 
of bed. Occasionally at this latter time it was altogether ab- 
sent, but not often. Again, it was always clearer, larger, and 
apparently nearer to him when he suffered from pain at the 
seat of the injury — as he did in paroxysms several times a 
day. At the times that he was free from pain, it disappeared 
when he shut his eyes, but, when the paroxysms were present, 
he saw it just as well with his eyes closed as when they were 
open. Pressing on either eyeball so as to destroy the par- 
allelism of the visual axes did not cause the production of 
two images, and then he made the discovery, by alternately 
shutting the eyes, that the hallucination only existed on the 
side corresponding to that on which he had been injured. He 
had, therefore, a unilateral hallucination such as those to 
which M. Regis * has recently called attention. I proposed 
trephining, but he declined to submit to the operation, and I 
finally lost sight of him. 

Hallucinations of hearing coexistent with integrity of the 
intellect are more common than those of any other of the 
special senses, and, according to my experience, are more apt 
to lead to further mental disorder. As Michea 2 says, quoting 
Theophrastus and Plutarch, the hearing is that one of the 
senses through which the passions are most readily excited. 
It is through the hearing that speech is perceived, without 
which the intelligence would be greatly restricted, through 
which the memory and the imagination are so extensively 
supplied with food, and through which, from childhood to 
old age, the mind is stimulated by recitals calculated to stir 
the emotions to their utmost pitch. Undoubtedly the mind is 
more capable of being influenced through the hearing than 
through any other sense by the continual repetition of the 
sensorial excitation. Far more people kill themselves under 
the influence of hallucinations of hearing than from those of 
all the other senses combined. The reiteration in the ears, 
during every minute of the day, of the command to commit 
suicide, to jump into the river, to blow the brains out, to 
take poison, to plunge a convenient knife into the heart, and 
so on, day in and day out, without intermission, is calculated 
to shake the power of control of the strongest minded, and 
it often does shake it. Few suicides or other acts of violence, 

1 "Des hallucinations unilaterales," L 1 Encepliale, Mars, 1881. 

2 Op. cit., p. 268. 

20 



306 DESCRIPTION AND TREATMENT OF INSANITY. 

comparatively, are perpetrated through hallucinations of the 
other senses. Those from hallucinations of sight are almost 
invariably connected with the idea of self-defence. 

Instances of hallucinations of hearing in those not other- 
wise insane abound in psychological literature, and are con- 
stantly coming under the observation of medical men. In 
their simplest form they consist of voices of various kinds ; in^ 
their more complex character they are words, sentences, and 
even long discourses. 

A patient of my own is subject to the hallucination — fre- 
quently repeated through the day and sometimes awaking 
him at night — of a sound close to his ears like that produced 
by striking two heavy books violently together. Another 
hears a tea-kettle hissing at a distance of a few feet from him, 
and another, a lady, is much annoyed by long-drawn sighs 
and moans like those which might come from a person in 
mental or physical suffering. Such hallucinating sounds 
must not be confounded with those intra-cranial or intra-aural 
noises produced by disturbances of the auditory apparatus. 
The latter always appear to be where they really are — in the 
head or ears, while the former are invariably referred to a 
position at some distance from the body. 

Baillarger 1 states that, during one of the street-fights in 
Paris, in April, 1831, the wife of a workman, returning to her 
home, saw her husband mortally wounded by a bullet. A 
month later she was confined, but on the tenth day after her 
accouchement delirium set in. In the very beginning of her 
mental disturbance she heard the sound of cannon, the firing 
of the platoons, the whistling of the balls. To avoid these 
sounds, she fled to the country, but was arrested and placed in 
the Salpetriere, where in a month she was cured. During the 
ensuing ten years she had six relapses, which always began 
by her hearing the discharges of cannon and muskets, and the 
hissing of bullets around her. 

Sometimes a single word or a few words constitute the hal- 
lucination. These are very apt to be of an obscene or profane 
character, or to consist of epithets of abuse. Thus, a gentle- 
man of education and refinement is constantly tormented by 
hearing a coarse word for sexual intercourse spoken into his 
ears in all tones, from a whisper to the voice of a stentor. 

1 " Des hallucinations," etc., " Meraoires de l'academie royale de medecine," t. 
xii, p. 279. 



PERCEPTIONAL INSANITIES. 307 

Another hears himself called "brigand," and another is con- 
stantly being told that he is a " damned fool." 

Again, they are commanded to do some particular act 
which it is repugnant to the individual to perform. Thus, one 
is told to hang himself, to throw himself from a precipice, to 
go up in a balloon, to kill a certain person, perhaps a near 
friend or relation, to commit arson or burglary, to blow up a 
house with dynamite, and a hundred other things mostly of 
the nature of crimes. Such hallucinations as these very often 
succeed eventually in overcoming the reason and with leading 
to the perpetration of the act ordered, or to some other incon- 
gruity indicative of advanced insanity. 

But no instance that has come under my observation equals 
that of a lady who hears recited to her long pieces of original 
poetry or prose, which, if not brilliant compositions, are still 
coherent, and sometimes above mediocrity. Usually they 
seem to come from a man speaking, as if addressing an audi- 
ence, and again they are whispered in a low tone like the 
voice of a child. She has repeatedly written down these reci- 
tations and brought them to me. I select the following as 
one of the best and shortest, premising that she wrote it in 
my presence after it had been, as she said, whispered into her 
ears all the morning : 

" Ah me, how sad and drear I feel, 

What withering fancies o'er me steal, 

And load my weary brain ! 

" I sit and dream from day to day 
Of that fair death for which I pray — 
For which I pray in vain. 

" Oh, God of fate, make sharp thy dart 
And pierce my aching, breaking heart, 
And set my spirit free. 

" My race on earth is nearly run, 
My thread of life is nearly spun, 
Oh, God, I long for thee." 
This lady had a strong hereditary tendency to insanity, 
and, shortly after the development of the hallucinations re- 
ferred to, she imbibed the delusion that she had committed 
the " unpardonable sin." She made two attempts at suicide, 
one by throwing herself into the water from a boat in which 



308 DESCRIPTION AND TREATMENT OF INSANITY. 

she was sailing with some friends, and another by taking 
laudanum. The last came very near being successful, but 
her life was saved, though with difficulty. She is still insane, 
but has — an unusual circumstance — lost the delusion of the 
" unpardonable sin," and contracted the idea that she has no 
bowels. She has no hallucinations of any kind, unless the 
sensations which she says she feels in her abdomen, and 
which, she describes, are those indicating the existence of a 
vacuum. 

As hallucinations of sight often exist while the eyes are 
closed, or in persons who are totally blind, so hallucinations of 
hearing continue though the ears be stopped, or originate in 
persons who are entirely deaf. I have already, in a previous 
chapter, cited the case of a deaf old lady who heard voices 
whispering to her. Another instance is that of a deaf-mute 
who came to my clinique at the University Medical College 
during the last session, and who was constantly subject to 
hallucinations of hearing of various kinds. Baillarger * men- 
tions the cases of five women, patients in the Salpetriere, who, 
being deaf, are yet subject to hallucinations of hearing. One 
of these, the deafest, hears the voices most distinctly. It is 
said that in the last years of his life Beethoven became com- 
pletely deaf, but that he heard his compositions as distinctly 
as when he actually listened to them when performed by an 
orchestra. 

Hallucinations of hearing, like those of sight, are some- 
times unilateral — that is, heard by only one ear. Baillarger a 
cites several examples of the kind. 

Calmet, 3 in relating the events which ensued at St. Maur, 
near Paris, in consequence of the supposed appearance of a 
ghost, gives some interesting details relative to hallucina- 
tions. A M. de S. was the observer, and he is described as a 
young man, short in stature, and well made for his height. 
After mentioning several circumstances connected with the 
apparition, Calmet goes on to state that, one afternoon, M. de 
S. entered his study, and, returning toward the door to go to 
his bedroom again, was much surprised to see it shut of itself 
and barricade itself with the two bolts that belonged to it. 
At the same time the two doors of a large press opened behind 

1 Op. tit., p. 310. 2 Op. tit., p. 260. 

8 " The Phantom World ; or, The Philosophy of Spirits, Apparitions," etc., 
by Augustus Calmet Edited by Rev. Henry Christmas, London, 1850, p. 291. 



PERCEPTIONAL INSANITIES. 309 

him and rather darkened his study, because the window which 
was open was behind these doors. 

" At this sight the fright of M. de S. is more easy to im- 
agine than to describe ; however, he had sufficient calmness 
left to hear, in his left ear, a distinct voice which came from 
a corner of the closet, and seemed to him to be about a foot 
above his head. This voice spoke to him in very good terms 
during the space of half a miserere, and ordered him, tJiee- 
ing and thouing him, to do some one particular thing which 
he was commanded to keep secret." 

Calmeil ' states that persons have told him that the sounds 
which they seemed to hear came to them sometimes by the 
right and sometimes by the left ear. 

Again, the voices appear to come from various parts of the 
body, such as the abdomen, the chest, the uterns, etc. These 
facts, however, in my experience, only occur with the subjects 
of well-marked insanity affecting other faculties of the mind 
besides the perceptions. They do not, therefore, come within 
the range of our consideration at present. 

Hallucinations of smell, though not so common as those 
of sight and hearing, are yet often met with independently 
of any aberration of the intellect. A gentleman of my ac- 
quaintance was almost constantly subject to the hallucination 
of smelling paint or turpentine, another had the odor of 
coffee ever present in his nostrils, and another, a physician, 
was always annoyed with the smell of the dissecting-room. 
It is well known that some epileptic seizures are preceded by 
the sensation of a horrible stench, which, as a gentleman sub- 
ject to epileptic paroxysms told me, was in his case like that 
of rotten fish. Hallucinations of smell are not so readily cor- 
rected by the intellect as those of sight and hearing, and it 
may sometimes be impossible for the subject of them to as- 
sure himself, in the beginning, of their nnreality. The persist- 
ency which they evince while serving to convince some per- 
sons that they cannot be actualities, will, on the other hand, 
have a contrary effect with individuals who may have a he- 
reditary predisposition to insanity, or who are under the influ- 
ence of some other cause. Thus, a patient whom I occasion- 
ally saw several years ago, and who suffered from hypochon- 
driacal mania, had a hallucination of the odor of fresh blood. 
For a long time he resisted the sensation, and endeavored in 

1 Art. " Hallucinations," " Dictionnaire de medecine," en 25 volumes. 



310 DESCRIPTION AND TREATMENT OF INSANITY. 

various ways to account for it, but at last it gained such an 
ascendency over him that he became convinced that his nose 
was continually bleeding, and that the blood was flowing 
down his throat. This made him very unhappy, and was the 
cause of his using all kinds of astringent douches and gargles 
for the purpose of stopping the flow. He wanted me to tie 
the carotid arteries in order to prevent him bleeding to death, 
a process which he was confident was going on rapidly. He 
almost starved himself in the endeavor to lower the action of 
the heart, and to this end also took various debilitating medi- 
cines. The hallucination had thus become a veritable delu- 
sion, although through its whole course not a single drop of 
blood had escaped from his nose or mouth. He neglected his 
business — that of a merchant tailor — and spent his whole time 
swabbing out his nostrils and gargling his throat. Somebody 
finally persuaded him that a journey across the plains would 
be of service to him. Fortunately he took the advice, and, 
after an absence of several months in Colorado and California, 
returned, entirely cured of his hallucination and delusion. 

Ecstatics, especially those of a religious character, are 
sometimes under the hallucination that delicious odors are 
being wafted to their nostrils, and they sniff the air with 
every manifestation of delight. 

Hallucinations of taste are not common. Indeed, it is 
sometimes difficult to say whether they exist or not, as vari- 
ous visceral irregularities may cause the production of tastes 
by modifications impressed upon the saliva. Mental excite- 
ment will cause a like effect in some persons. I am ac- 
quainted with a gentleman who cannot participate in any en- 
grossing conversation without having a bitter taste developed 
in his mouth. An exciting dream will, as he tells me, pro- 
duce it. 

Hallucinations of the sense of touch are, on the other hand, 
very frequently met with, not only in the insane, but in indi- 
viduals of otherwise complete mental integrity. Sensations 
apparently not based on any real impression are experienced 
in various parts of the body. It is difficult, however, to dis- 
criminate between illusions and hallucinations of touch. 
Probably the majority of the false perceptions connected 
with touch belong to the first-named category. This seems to 
be especially the case with visceral sensations, and the feeling 
of lightness or weight of body, to which reference has already 



PERCEPTIONAL INSANITIES. 311 

been made. The former, whether of the nature of illusions or 
hallucinations, are common symptoms of hypochondriacal 
mania, and are often the starting-point of this disorder. 

Baillarger ' was the first to describe a peculiar kind of hal- 
lucination, generally of hearing, in which the individual has 
the impression derived from words being spoken to him, but 
in which he does not hear sounds. It is a kind of intellectual 
hallucination, not being directly connected with the organ of 
sense to which it is referred. The voices, which appear to 
come from various parts of the body, such as the chest or 
stomach, are, according to Baillarger, not recognized by the 
individual as real sounds, but are only ideas of sounds, which, 
however, impress him with as much force as though they 
were spoken directly into his ear. I am quite sure that this 
is not always the case. I have under my care at this time a 
patient who hears voices speaking to him from his epigastrium, 
and to whom they appear as real sounds ; moreover, these 
psychical hallucinations are never found except in those lu- 
natics in whom the intellect is involved. 

Occasionally persons have the power of voluntarily produc- 
ing hallucinations of various kinds. A practice, fraught with 
danger for the time, is apt to come, sooner or later, at which 
they cannot get rid of their false perceptions. As an instance 
of the facility with which hallucinations, especially of vision, 
may be formed, and of the ill consequences which may result 
from the practice, I cite the following case from Wigan. 3 
The painter referred to is Blake. 

" A painter, who inherited much of the patronage of Sir 
Joshua Reynolds, and believed himself to possess a talent su- 
perior to his, was so fully engaged that he told me he had 
painted three hundred large and small portraits in one year. 
The fact appeared physically impossible, but the secret of his 
astonishing success was this : he required but one sitting of 
his model. I watched him paint a portrait in miniature in 
eight hours of a gentleman whom I well knew ; it was care- 
fully done, and the resemblance was perfect. I begged him 
to detail to me his method of procedure, and he related what 
follows. 

" When a sitter came, I looked attentively on him for half 
an hour, sketching from time to time on the canvas. I did 

1 Op. cit, p. 383. 

3 " A New View of Insanity. The Duality of the Mind." London, 1844, p. 123. 



312 DESCRIPTION AND TREATMENT OF INSANITY. 

not require a longer sitting. I removed the canvas and passed 
to another person. When I wished to continue the first por- 
trait, I recalled the man to my mind ; I placed him on the 
chair, where I perceived him as distinctly as if he were really 
there, and, I may add, in form and color more decided and 
brilliant. I looked from time to time at the imaginary figure, 
and went on painting, occasionally stopping to examine the 
posture as though the original were before me. Whenever I 
looked toward the chair I saw the man. 

"This method made me very popular, and, as I always 
caught the resemblance, the sitters were delighted that I 
spared them the annoying sittings of other painters. In this 
way I laid by much money for myself and my children. 

"By degrees I began to lose all distinction between the 
imaginary and the real figure, and I sometimes insisted to 
my sitters that they had set the day before. Finally I' was 
persuaded that it was so, and then all became confusion ; I 
recollect nothing more. I lost my reason, and remained for 
thirty years in an asylum. With the exception of the last six 
months of my confinement, I recollect nothing ; it, however, 
appears to me that, when I hear persons speak of their visits 
to the establishment, I have a faint recollection of them." 

It is related of Talma, the great actor, that he could, by the 
power of his imagination, cause the audience to appear like 
skeletons, and that, when the hallucination was complete, his 
histrionic genius was at its height, through the effort pro- 
duced upon his emotions, and he produced the most vivid 
effects upon all who heard him. 

Goethe states that he had the power of giving form to the 
images passing before his mind, and upon one occasion saw 
his own figure approaching him. Wigan states that he knew 
a very intelligent man who also had this power. 

Abercrombie ' refers to the case of a gentleman who had 
all his life been affected by the appearance of spectral figures. 
To such an extent did this peculiarity exist that, if he met 
a friend in the street, he could not at first satisfy himself 
whether he saw a real or an imaginary person. By close at- 
tention he was able to determine that the outline of the false 
was not so distinct as that of the real figure, but generally he 
used other means — such as touch, or speech, or listening for 
the footsteps — to verify his visual impressions. He had also 

lu Inquiries Concerning the Intellectual Powers," etc!, London, 1840, p. 380. 



PERCEPTIONAL INSANITIES. 313 

the power of calling up spectral figures at will, by directing 
his attention steadily for some time to the conceptions of his 
own mind, and these either consisted of a figure or a scene he 
had witnessed or a composition created by his imagination. 
But, though he had the faculty of producing hallucinations, 
he had no power of banishing them, and, when he had once 
called up any particular person or scene, he could never say 
how long it would continue to haunt him. This gentleman 
was in the prime of life, of sound mind, in good health, and 
engaged in business. His brother was similarly affected. 

Several like cases have come under my own observation. 
In one, the power was directly the result of attendance at 
spiritual meetings, and of the efforts made to become a good 
"medium." The patient, a lady, was of a very impression- 
able temperament, and was consequently well disposed to ac- 
quire the dangerous faculty in question. At first she thought 
very deeply of some particular person, whose image she en- 
deavored to form in her mind. Then she assumed that the 
person was really present, and she addressed conversation to 
him, at the same time keeping the idealistic image in her 
thoughts. At this period she was not deceived, for she clear- 
ly recognized the fact that the image was not present. 

One day, however, she was thinking very intently of her 
mother, and picturing to herself her appearance as she 
looked when dressed for church on a particular occasion. 
She was reading a book at the time ; happening to raise her 
eyes, she saw her mother standing before her exactly as she 
had imagined her. At first she was somewhat startled, and, 
in her agitation, closed her eyes with her hands. To her sur- 
prise she still saw the phantom, but yet, not being aware of 
the centric origin of the image, she conceived the idea that 
she had really seen her mother's spirit. In a few moments it 
disappeared, but she soon found that she had the ability to 
recall it at will, and that the power existed in regard to many 
other forms — even those of animals and of inanimate objects. 

During the spiritualistic meetings she attended, she could 
thus reproduce the image of any person upon whom she 
strongly concentrated her thoughts, and was for a long time 
sincere in her belief that they were real appearances. At last 
she lost control of the operations, and became constantly sub- 
ject to hallucinations of sight and hearing. She was unable 
to sleep, and complained of vertigo, pain in the head, and of 



314 DESCRIPTION AND TREATMENT OF INSANITY. 

other symptoms indicating the existence of cerebral hypere- 
mia. The application of ice to the vertex and nape of the 
neck, and other suitable medication, saved her from an at- 
tack of insanity of a higher grade than that from which she 
was suffering, but her nervous system was for several months 
in a state of exhaustion, from which she rallied with diffi- 
culty. 

A young lady once informed me that she was able to bring 
visually before her the images of any novel she may have 
been reading, or of any striking play she may have witnessed. 

It is probable that many of the visions of Jerome Cardan 
and of Swedenborg were induced in much the same way. ~No 
one presumes to question the honesty of either of these dis- 
tinguished men, but both were impressionable to an extreme 
degree, and, doubtless, mental concentration of an intense 
character, and long continued, was the agent in the produc- 
tion of the visions of which they were the subjects. In some 
persons very slight thought is sufficient to cause hallucina- 
tions of great distinctness. 

Thus, a married lady consulted me for hallucinations of 
sight and hearing, from which she had suffered for several 
months. It was only necessary for her to think of some par- 
ticular person, living or dead, when she immediately saw the 
image of the person thought of, who spoke to her, laughed, 
wept, walked about the room, or did whatever other thing 
she imagined. In fact, to such an extent had her proclivity 
reached that it was often impossible for her to avoid think- 
ing of persons, and immediately having their figures brought 
to her perception. 

At first she religiously believed in the reality of her vis- 
ions, and that she really saw the spirits of the various indi- 
viduals of whom she happened to think. But, as the halluci- 
nations became more common, she lost her faith, and ascribed 
them to their true cause — disease. Upon examination, I found 
that she was pre-eminently of a hysterical type of organiza- 
tion, and was then laboring under other symptoms of its pres- 
ence besides the hallucinations. Thus, she had hysterical 
paralysis of motion and sensibility in the right leg to such 
an extent that she could neither move it nor feel a pin 
thrust through the skin. Her pulse was small and weak, her 
appetite capricious, and her complexion pale. Not the least 
of her afflictions was an almost perpetual headache. Under 



PERCEPTIONAL INSANITIES. 315 

the administration of treatment directed to the relief of what 
I considered to be an ansemic brain, she entirely recovered. 

Quite recently, Mr. Francis Gfalton, 1 in a paper which, 
though interesting to the lay reader, cannot but excite, on 
some accounts, a feeling of disapproval in the minds of neu- 
rologists, advises the cultivation of the faculty of forming 
mental images. The ability to recall desirable impressions is 
one which is developed in different degrees in different people, 
and it is one which may be exercised not only without detri- 
ment but with advantage to the individual. It is simply an 
instance of the power of memory, and its exercise leads to 
close and exact observation. But this is a very different 
thing from forming images which are not transmitted to the 
brain through the retina and optic nerve, and the perception 
of which is therefore purely imaginary. It is, in fact, the vol- 
untary production of a hallucination. As Mr. Galton says, 
the power is very high in some young children, who seem to 
spend years of difficulty in distinguishing between the subjec- 
tive and the objective world. Undoubtedly the high cultiva- 
tion of this faculty by adults would lead to like inconven- 
ience, and probably disease. My own experience, as well as 
that of others to whom I have referred, is sufficient to assure 
me of the great danger of developing a power which we all 
possess to some extent, and it would be very easy to adduce 
other instances, besides those given, of the disastrous results 
likely to ensue from the indiscriminate adoption of Mr. Gal- 
ton's views. 

Perceptional insanity, either in the form of illusions or 
hallucinations, or both these varieties of sensorial derange- 
ment, may make its appearance suddenly, the first evidence 
of its presence being the illusion or hallucination. Usually, 
however, there are prodromata indicating the existence of 
cerebral derangement. These are, pain in the head, irritability 
of temper, suffusion of the eyes, noises in the ears, a general 
restlessness, inability to sleep, unpleasant and vivid dreams, 
and some febrile excitement. The skin is generally dry, the 
mouth parched, the bowels costive, and the urine high col- 
ored. If not arrested, it may pass into a higher form of men- 
tal derangement. 

Causes. — The causes of central illusions and hallucinations 
are generally to be found in derangements of some kind in the 

1 "Mental Imagery," Fortnightly Review, September, 1880. 



316 DESCRIPTION AND TREATMENT OF INSANITY. 

blood circulating in the brain. These may either relate to its 
quantity or its quality. 

Physical influences calculated to produce cerebral hypere- 
mia or congestion may give rise to illusions or hallucinations. 
Brierre de Boismont 1 refers to a case, on the authority of Mo- 
reau, in which an individual was able to obtain hallucinations 
of sight by inclining his head a little forward. By this move- 
ment the return of blood from the brain was impeded, and 
the functions of the ganglia for vision were unduly exalted. 
A similar case was not long since under my own care. A 
gentleman, while sitting at his table writing, happened to 
raise his eyes from the paper without moving his head, and 
was astonished to see before him the figure of an old woman 
with black cloak and hood. Throwing himself back in his 
chair in his amazement, he was again surprised to find that 
the image slowly disappeared ; and, as often as he repeated 
these movements, a like series of phenomena occurred. A 
few days afterward he repeated the circumstances to me, and, 
on examining him, I found that he wore a very high old-fash- 
ioned stock, which, as he sat at the table with his head bent 
forward, compressed the large veins of the neck, and pre- 
vented for a time the return of blood from the brain. On 
changing his neck- wear for other of more modern fashion, he 
was enabled to bend his head and raise his eyes without en- 
countering the apparition. 

An instance showing the influence of position in giving 
rise to false perceptions is given in Nicholson '<? Journal : 2 
"I know a gentleman," says the narrator, "in the vigor of 
life, who, in my opinion, is not exceeded by any one in ac- 
quired knowledge and originality of deep research, and who, 
for nine months in succession, was always visited by a figure 
of the same man threatening to destroy him, at the time of 
his going to rest. It appeared on his lying down, and in- 
stantly disappeared when he resumed the erect position." 

A gentleman who stands high as an author consulted me 
for a similar trouble. For several weeks he had been visited, 
just as he lay down, by the figure of a very old man, who 
stood by the side of his bed grinning and beckoning to him 
with one finger. At first he was deceived, and, starting sud- 
denly from his bed, endeavored to seize his visitor, but he 

1 " A History of Dreams, Visions, Apparitions," etc., American edition, 
Philadelphia, 1855, p. 370. s Vol. vi, p. 166. 



PERCEPTIONAL INSANITIES. 317 

was gone before lie could fairly stretch out liis hands. He 
again laid down, and again the figure appeared. He reached 
out with one arm and convinced himself that he could touch 
the very place where the image apparently stood, but he 
grasped nothing. He shut both eyes, and then each eye alter- 
nately, but it still remained. He was then entirely satisfied 
as to its real character, and so, like a sensible man, tried to 
get to sleep, but in this attempt he succeeded badly. He al- 
lowed this to go on for several weeks before he concluded to 
seek medical advice. 

Dendy J mentions the case of a gentleman of high attain- 
ments who was constantly haunted by a spectre, when he 
retired to rest, which seemed to attempt his life. When he 
raised himself in bed, the phantom vanished, but reappeared 
as he resumed the recumbent posture. 

The explanation of such cases is very simple. The recum- 
bent posture facilitates the flow of blood to the brain, and at 
the same time tends, in a measure, to retard its exit. Hence, 
the appearances were due to the resulting congestion. As 
soon as the individuals rose in bed, or stood erect, the reverse 
conditions existed, the congestion disappeared, and the appa- 
ritions went with it. 

Hallucinations of hearing are also sometimes produced by 
like causes. I had occasion recently to treat a lady suffering 
from epilepsy, and one of the means I advised for her relief 
was the wearing of an elastic band around the neck so as to 
compress the veins. After wearing it a few days, she com- 
plained of great fulness of the head and continual noises in 
the ears. Sometimes these were of a soft, moaning character, 
and at others like the hissing of a tea-kettle. I advised her, 
however, to persevere, which she did for another week, when 
she returned to say that she constantly heard voices singing 
all kinds of ribald words to familiar tunes. At first she had 
rather liked this, but it soon began to grow tiresome, and had 
kept her from sleeping. She had, accordingly, taken off the 
band, and at once the sounds had ceased. 

In another case, the patient, a young man, heard a voice 
whispering to him in the ear which rested on the pillow. 
When he turned over in bed, the voice at once disappeared, 
but in about a minute was heard in the ear which was then in 
contact with the pillow. 

1 "The Philosophy of Mystery, 1 ' London, 1841, p. 290. 



318 DESCRIPTION AND TREATMENT OF INSANITY. 

The influence of cerebral hyperemia in causing halluci- 
nations would, therefore, seem to be clearly established by 
actual experiment. Ferriar l wrote a treatise with the special 
object of proving that this is the only cause ; but this is an 
extreme view which cannot be sustained, for, as we shall pres- 
ently see, the very opposite condition, cerebral anaemia, may 
give rise to them in a very marked degree. 

That cerebral ancemia is an immediate cause of halluci- 
nations is seen in the facts that during starvation, and other 
conditions producing great bodily exhaustion, hallucinations 
are common occurrences. As I have said in another work : 9 
" Hallucinations and illusions are common in the slowly de- 
veloped forms of cerebral ansemia, and may affect any one or 
all of the senses. Those of sight and hearing are, however, 
more prominent. In the case of a young lady under my care, 
and whose only marked disease was that [cerebral ansemia] 
under consideration, the hallucination that she saw a black 
man was almost constantly present. At times she conversed 
with this imaginary being, told him not to trouble her, that 
she no longer feared him," etc. 

A more striking instance has, however, recently come 
under my observation, which shows, undoubtedly, that a re- 
duction in the amount of blood circulating within the cra- 
nium may give rise to hallucinations. A young woman af- 
fected with epilepsy was of a very gross habit of body, and 
suffered from many attacks of the petit mat every day. 
While in my consulting-room, she had repeated seizures, and, 
with the view of arresting them, I exerted strong pressure on 
both carotid arteries, according to the method recommended 
by Dr. Corning, of this city. Her face instantly became pale, 
and, without losing consciousness, she uttered a loud shriek, 
and pointed with her finger at an object which she apparently 
saw near her. I at once discontinued the pressure, when she 
informed me that she had seen an immense negro man rush- 
ing toward her with a club, and that as soon as I had stopped 
pressing on her neck the figure had disappeared. I assured 
her it was a hallucination, and, after much persuasion, in- 
duced her to let me repeat the experiment. As soon as the 
pressure on the arteries was made, she saw the figure ap- 

1 " An Essay toward a Theory of Apparitions," London, 1813. 
2 " A Treatise on the Diseases of the Nervous System," first edition, New- 
York, 1871, and subsequent editions. 



PERCEPTIONAL INSANITIES. 319 

proaching her with a club. " There he is ! there he is ! " she 
exclaimed. I continued to press, and she soon became insen- 
sible. On removing the pressure, she at once regained con- 
sciousness, and explained that the figure was exactly the 
same as she had at first seen. I now exerted moderate press- 
ure, with the view of keeping it up for some little time. In 
about half a minute she said that she saw the figure, but not 
very distinctly. I made more pressure, and then she stated 
that she saw him very clearly. I found that I could make 
the figure distinct or indistinct by varying the degree of 
pressure. 

Michea ' divides the causes of hallucinations — embracing 
under this term illusions also — into two classes, material and 
psychological. In the first category are included electricity, 
great variations of temperature, the abuse of alcoholic liquors, 
or the sudden deprivation of these agents with persons accus- 
tomed to them, large doses of sulphate of quinine, digitalis, bel- 
ladonna, stramonium, hyoscyamus, opium and its compounds, 
Indian hemp, nux vomica, camphor, lead, nitrous oxide 
(when inhaled), suspension by the neck, simple pressure upon 
or mechanical irritation of any of the organs of the special 
senses, cerebral shock, starvation, heredity, intestinal worms, 
diminution or total absence of light, the middle period of 
life, and notably that between thirty-five and forty-five years, 
in the female sex. 

These data rest almost entirely on the dicta of other per- 
sons, and many of the alleged causes are probably more fanci- 
ful than real. 

The psychological causes are, according to the same author, 
the prolonged continuance of the same sensation, a too vivid 
impression made upon any organ of sense, revery, or the pro- 
longed concentration of the faculty of attention, solitude, re- 
morse, fright, sorrow, extreme ambition, humiliation. 

In looking over these lists of causes, it is perceived that 
many of them refer to illusions which are not of centric origin, 
and which, therefore, have nothing to do with mental aberra- 
tion. Hallucinations can never be produced by irritations 
applied to an organ of sense, except by such irritation pro- 
ducing centric disturbance, as it sometimes does. I have seen 
several cases of illusions and hallucinations of hearing pro- 
duced by impacted cerumen, but in all these cases there were 

1 Op. cit., p. 264. 



320 DESCRIPTION AND TREATMENT OF INSANITY. 

unmistakable evidences of the existence of cerebral hypere- 
mia, to which the sensorial disturbances were directly due. 

Baillarger, 1 speaking of the influence of certain drugs in 
causing hallucinations, mentions the fact that hashish (Indian 
hemp) produces the sensation of an elongation of the limbs 
and a swelling of the body such as we may suppose was ex- 
perienced by the blessed Ida, whose case I have cited. I have 
repeatedly noticed this fact, and likewise the additional cir- 
cumstance also mentioned by Baillarger, that opium and 
stramonium give rise to similar sensations. Peculiar illusions 
and hallucinations are said to be caused by other drugs, but 
I have never found any marked degree of uniformity in this 
respect, except as regards the bromide of potassium and other 
bromides, which certainly, when carried to extreme points 
in administration, often cause hallucinations of seeing dead 
or dying persons. 2 Moreover, all the sensorial aberrations 
produced by these drugs are of distressing or sorrowful char- 
acter. 

As Baillarger s has pointed out, the state between sleeping 
and waking is that during which hallucinations are particu- 
larly apt to occur, and he cites many cases in illustration of 
the fact. I have already in a previous chapter, "The Physi- 
ology of Dreams," called attention to this interesting circum- 
stance, which, under the name of "hypnagogic hallucina- 
tions," has been so thoroughly studied by M. Maury. 

Children are very liable to be subject to hallucinations, 
and frequently give circumstantial accounts of apparitions 
and incidents which they believe have occurred to them, of 
voices they have heard, etc. — and this with an earnestness of 
exi)ression and attention to detail which show that they are 
sincere in the stories they tell. It is often impossible for them 
to discriminate between the true and the false, and I am afraid 
they are often punished for lying by ignorant parents when 
they have told nothing but what they have had the evidence 
of their senses for believing. The explanation of this pro- 
clivity is to be found in the fact that they are possessed of a 

1 Op. cit., p. 353. 

2 See paper, by the author, "On some of the Effects of the Bromide of Potas- 
sium when administered in Large Doses," Quarterly Journal of Psychological 
Medicine, vol. iii, 1869, p. 46. 

3 " De l'influence de l'6tat intermediate a la veille et au sommeil sur la pro- 
duction et la marche des hallucinations," " Memoires de l'acad6mie royale de 
medecine," t. xii, p. 476. 



PERCEPTIONAL INSANITIES. 321 

degree of nervous development out of proportion to that of 
the rest of their body, and are hence impressionable to a high 
degree. Moreover, they have not the necessary experience in 
the use of their sensorial organs or the intellectual develop- 
ment essential to the discrimination between the unreal and 
the real. 

Pathology and Morbid Anatomy. — A great deal has been written 
relative to the physiology of hallucinations, but without much 
result so far as any explanation of the process is concerned. 
As we cannot elucidate the question of the perception of real 
images and of other sensorial impressions by any experiments 
or investigations we can make, so we equally fail in our at- 
tempts to unravel the mystery of false images, false voices, 
tastes, smells, and tactile impressions. In the normal state 
of the brain we obtain perceptions which we believe to be 
true ; in the abnormal state we form perceptions which some- 
times we ourselves, and again those about us, are convinced 
are erroneous. The difference is to be ascribed to the change 
which has taken place in the perceptional centres. This 
change may consist of a state of temporary or permanent 
congestion, temporary or permanent anaemia, the circulation 
of blood through them which has acquired toxic properties, 
or the existence of structural disease. 

There is some evidence to show that the thalami optici 
are the centres for all real perceptions, and that hence they 
are the organs which, through their disease, give rise to all 
centric illusions and hallucinations. If these bodies be di- 
vided centrally antero-posteriorly, they will be seen to have 
embedded in their substance four ganglionic masses. Of 
these, three are ranged along the superior surface of each 
thalamus, and from their positions may be designated the 
anterior, middle, and posterior, while the other, more deeply 
placed, may be called the central. 

Luys, 1 who has studied the formation of the thalami op- 
tici with great thoroughness, designates these nuclei, from al- 
leged anatomical and physiological relations, respectively, the 
olf active, the optic, the acoustic, and the sensitive, or gan- 
glion of general sensibility. 

It is true that Meynert 2 only half acknowledges their ex- 

1 " Recherches sur le systeme nerveux,' 1 etc.. Paris, 1865, p. 108, et seq. 
2 Article on "The Brain of Mammals," in "Strieker's Manual of Histology," 
American edition, p. 690. 
21 



322 DESCRIPTION AND TREATMENT OF INSANITY. 

istence, contending that the appearance of distinct nuclei is 
due to the mode of distribution of the fasciculi of fibres 
which enter and leave the thalamus, and that Huguenin 1 
adopts this view of the subject. Really, however, this point 
is of no special importance so far as its bearing on the pa- 
thology of illusions and hallucinations is concerned. That 
the optic thalami, either by distinct nuclei or by themselves 
as bodies composed of ganglionic cells, are distinctly con- 
nected with the organs of the special senses referred to, in the 
relation of being their nervous centres, is, I think, a matter 
capable of complete demonstration. 

The connections of the optic thalami with sensibility were 
first pointed out by Magendie, 2 who ascertained that their 
irritation in animals produced excessive pain, while the other 
parts of the brain might be invaded without causing evidences 
of suffering. 

Although Todd, Carpenter, and others have regarded the 
optic thalami as centres for sensorial impressions, Luys 3 more 
than any other physiologist has elaborated this idea, and has 
adduced arguments in its support which it is difficult to over- 
look. His doctrine is that the optic thalami are reservoirs for 
all sensorial impressions coming from the periphery of the 
nervous system, and that, like other ganglionic masses, they 
elaborate these impressions, and that, by means of the fibres 
of the corona radiata, they transmit them to the cortex, to be 
still further perfectionated by being converted into ideas. 
In his own language : 3 

" All sensorial impressions, after having been received and 
concentrated in the gray substance of the optic thalami, are 
irradiated toward the different regions of the cortical periph- 
ery. The white central substance transmits them, and the 
gray substance of the convolutions receives and elaborates 
them." 

Many facts in morbid anatomy go to support this view of 
the relation between the sensorial organs and the optic thala- 
mi. Twenty-six cases have been collected by Ritti 4 from 
Hunter, Treviranus, Serres, Lancereaux, Cruveilhier, Andral, 
Marce, Lallemand, Laborde, Luys, Yoisin, and others, to the 
effect of sensorial disturbances existing during life in connec- 

1 " Anatomie des centres nerveux," French translation by Heller, Paris, 1879, 
p. 104. a Op. cit., p. 344, et seq. 3 Op. cit., p. 346. 

4 " Theorie physiologique de l'hallucination," Paris, 1874, p. 37. 



PERCEPTIONAL INSANITIES. 323 

tion with disease involving the optic thalami discovered after 
death. 

But it is not alone to morbid anatomy that we are to look 
for evidence of this relation. Experimental physiology equal- 
ly tends to its establishment, and, though the position of the 
optic thalami is such as to make it a matter of difficulty to 
act upon them as in the case of the cortex, the obstacle has 
been in a great measure overcome by Fournie, and we are 
thus placed in possession of data which have a distinct con- 
nection with the point at issue. 

Fournie' s 1 method consisted in injecting, by means of a 
hypodermic syringe, caustic solutions — such as a strong solu- 
tion of the chloride of zinc — into the brain of a dog, observ- 
ing the resulting phenomena, and then, after death, carefully 
noting the part of the organ in which the injection had been 
deposited. Seven of his experiments related to the optic 
thalami, and, without referring to the other results, it may 
be stated that in every one there was a more or less complete 
loss of sensation. 

Thus, in Case XV, the left side was operated upon. The 
needle traversed the cornu ammonis, and the injection was 
thrown out in the centre of the optic thalamus. As a conse- 
quence, there was complete abolition of all sensibility. 

Such being apparently the physiological relations of the 
optic thalamus, we come in the next place to discuss, with 
something more of fulness, the consequences, so far as sensa- 
tion is concerned, of certain abnormal states of these organs. 
As I have said, Ritti has collected from various sources 
many cases proving that injury or disease of the optic thala- 
mi leads to sensorial derangement, or the entire loss of one 
or more of the special senses. He has also gathered together, 
from the works of Calmeil, Lagardelle, and others, instances 
tending to establish the fact that hallucinations are the re- 
sult of disease of one or both optic thalami. Several of the 
cases were supplied to him by M. Aug. Voisin, and had not 
previously been published. Of these latter I quote the fol- 
lowing : 

" A woman, aged forty-one, entered the Salpetriere, Jan- 
uary 30, 1867. Since 1865, she has been subject to halluci- 
nations of sight, accompanied at times by some excitement 
and partial alienation. At her admission she had partial 
1 " Sur le fonctionnement du cerveau," Paris, 1873. 



321 DESCRIPTION AND TREATMENT OF INSANITY. 

hallucinations of sight and hearing, and others connected 
with the genital organs. There were also delusions of percep- 
tion. Latterly the sense of hearing has been impaired. She 
died, April 17, 1869, of typhoid fever. 

" Autopsy. — Neither thickening nor adhesions of the mem- 
branes ; no sub-arachnoid effusion ; cranial nerves normal, 
with the exception of the eighth pair, which were rotten. At 
the most posterior and internal part of the two lobes of the 
cerebellum, and in the region nearest to the olivary bodies, 
there were collections of little granulations such as are seen 
in the choroid plexus. These were continued as far as the 
floor of the fourth ventricle, where they covered its cerebel- 
lar wall. Nothing was found wrong with the left optic thala- 
mus, but the gray anterior centre of the right thalamus was 
more than normally vascular, and in the part immediately 
subjacent to the olf active centre of gray matter there was a 
spot the color of the dregs of wine, due to a globiform extra- 
vasation of blood. In the middle region there was a lacuna." 

This case is instructive, not only on account of the situ- 
ation of the lesion, but for the reason, also, that there was no 
other intracranial disease to which the symptoms could have 
been ascribed. 

In a case that came under my own observation, a patient 
had hallucinations of sight and hearing, while at the same 
time he was both blind and deaf. The blindness and deaf- 
ness had existed for several years, but there were no hal- 
lucinations or other abnormal mental disturbances till, in the 
month of October, 1877, on successive days, the 12th and 
13th, there were paralytic seizures without coma, on each oc- 
casion soon after waking in the morning. The motor pa- 
ralysis was slight, and almost entirely disappeared in a few 
days, but the cutaneous anaesthesia was persistent to the day 
of his death, on December 10th following. The examination 
of the brain was made by me on December 11th. There was 
a clot the size of a small bean in each optic thalamus. These 
were apparently several weeks old, and were, doubtless, the 
cause of the paralytic attacks and hallucinations in October. 
The immediate cause of death was a fresh haemorrhage into 
the pons Varolii, which had broken through the substance of 
the organ into the sub-arachnoid space. There was no other 
evidence of brain disease. 

That the optic thalamus is the centre for perception, as 



PERCEPTIONAL INSANITIES. 325 

the cortex is for intellection, is, to say the least, exceedingly 
probable. Every sense has these two stages in its full action. 
Something is perceived; that is one stage. It is more or less 
thoroughly understood ; and that is the second stage. A pig- 
eon, for instance, from which the cerebrum has been removed, 
leaving only the basal ganglia, perceives, but does not under- 
stand. A light may be held before the eyes, and the head is 
turned if the light be moved, so that it can still be seen. 
If a loud noise be made near by, the animal starts or turns its 
head in the direction of the sound. These phenomena show 
perception, but they just as clearly show the absence of intel- 
lection, for the animal does not do the thing which, if it 
understood, it would do ; it obtains no idea from the sen- 
sorial impression, and it is equally incapable of originating 
an idea, for it is deprived of consciousness. Consequently, it 
gives no evidences of alarm, no matter how intense the visual 
or auditory excitation may be. It perceives, as is very evi- 
dent from its actions, but these actions are such as to show 
that there is no further elaboration of the impression. 

The intrinsic starting-point of every real sensorial impres- 
sion is an organ of sense, such as the eye, the ear, or the 
terminal ramifications of the olfactory nerves. The starting- 
point of an erroneous sensorial impression — illusion or hallu- 
cination — may be either the organ of sense concerned therein 
or the sensory ganglion — the optic thalamus. The cortex, or 
intellectual centre for any sense, cannot form a real or false 
sensorial impression. It can only elaborate the impressions 
which reach it from the sensory ganglion, and these are either 
true or false, real or unreal, according as they come originally 
from the ganglion or are transmitted through it from an or- 
gan of sense receiving real impressions from without ; and ac- 
cording as the cortex is in a normal or an abnormal condition 
will the ideas or beliefs which it forms from these transmitted 
impressions be normal or abnormal. It is true the cortex can 
recall former impressions and construct ideas from them, but 
here the idea is based on a recollection and not on a senso- 
rial impression. Till, for instance, the eye and the optic 
thalamus had received the image of an American Indian and 
perceived it, the cortex could not have formed an idea of such 
a being. All, therefore, that the cortex does is to take cog- 
nizance of present or former sensorial impressions which it 
receives or has received from the optic thalamus, and to form 



326 



DESCRIPTION AND TREATMENT OF INSANITY. 



ideas from them. It does this normally when we bring the 
memory into action in a reasonable and logical manner ; it 
does it abnormally, for instance, in delirinm without hallu- 
cinations, but in which there is a constant recurrence, in a dis- 
orderly manner, of ideas previously formed from former sen- 
sorial impressions. The accompanying diagram (Fig. 5) will 
tend to the elucidation of the views here expressed. 

A is an organ of sense, the eye. Through the optic nerve 

Fig. 5. 




B an impression received on the retina is transmitted to the 
sensory ganglion, the optic thalamus (7, when it becomes a 
perception. From the optic thalamus it is transmitted by 
fibres of the corona radiata D to the cortex E, where it is 
elaborated into an idea ; and from the cortex another form of 
force may be evolved, and an intelligent action may take 
place in consequence of the transmission through another set 
of fibres, F, of a motor impulse to a muscle, G. If there is no 
organ of sense, there can be no normal sensorial impression ; 
if the optic nerve be divided, the sensation cannot be trans- 
mitted to the optic thalamus ; if there be a diseased optic 
thalamus, the sensorial impression will be perverted, and there 
will be an illusion of centric origin ; if the cortex be in a nor- 
mal condition, this illusion will be corrected and understood 
as such erroneous perception ; if, however, the cortex be dis- 
eased, the illusion will be accepted as true, and a false idea, or 
delusion, will be formed. If the organ of sense receives no im- 
pression from without, but if such impression be formed in 
the optic thalamus, then there is a hallucination ; if, again, 



PERCEPTIONAL INSANITIES. 327 

the cortex be healthy, this hallucination is appreciated at its 
full value, and there is a true idea in regard to it ; if, on the 
other hand, the cortex be in an abnormal state, the halluci- 
nation is accepted for reality, and a delusion is the result. 

Such is, I think, the pathology of perceptional insanity. 
The lesions of the optic thalamus necessary to the production 
of a false sensorial impression may be of varied character. 
Congestion is probably that which most commonly exists, es- 
pecially in the early stages, and in those cases which are not 
accompanied by derangements of the other categories of men- 
tal faculties. Ansemia is likewise a condition of frequent oc- 
currence. At later periods, as Luys s says, the optic thalami 
are the seats of degenerations which show that there have 
been frequent perturbations of the circulation. Sometimes 
there is a little hemorrhagic focus in different stages of re- 
gression, and, again, various stages of sclerosis. This sclerosis 
is accompanied by partial hyperemia and the production of 
a large number of amyloid corpuscles. The nerve cells are 
correspondingly diminished in number, and those which re- 
main have undergone degeneration and atrophy. 

Luys 2 appears to have established the point that in old 
cases of hallucinations there is a special form of cortical dis- 
ease affecting the paracental lobe, and which consists of a hy- 
pertrophy of this part of the cerebrum on one or both sides. 
The region in question, therefore, is raised up above the sur- 
rounding parts, and presents a gibbous appearance. Incision 
into the affected portion shows that the convolutions are in- 
creased in size, and that a state of hypersemia exists. Again, 
there may be atrophy, especially of the frontal convolutions, 
or a general diminution of the weight of the brain may exist. 

But he is very strong in his conviction that there are sec- 
ondary changes, which are the cause of the transformation of 
psycho-sensorial hallucinations into those which Baillarger 
designated psychic, and to which attention has already been 
called. In my opinion, they are the cause of the hallucina- 
tion becoming a delusion, and, indeed, between a psychic hal- 
lucination and a delusion there is very little difference. The 
former cannot exist without the involvement of the intellect. 

1 " Traite clinique et pratique des maladies mentales," Paris, 1881, p. 305. 

2 Op. cit., p. 392. 



328 DESCRIPTION AND TREATMENT OF INSANITY. 

CHAPTER IV. 
ii. 

INTELLECTUAL INSANITIES. 

The intellectual insanities are characterized by the pre- 
dominance of intellectual derangement. It is not to be con- 
sidered for a moment that the perceptions, the emotions, 
and the will are not also often involved to a marked degree ; 
but, in the forms which I have placed under this head, the 
intellect is that part of the mind which is pre-eminently dis- 
turbed. They are mainly characterized by the existence of 
delusions, and, if the reader will bear in mind what has been 
said in regard to delusions, he will at once perceive that they 
involve the intellect directly and necessarily, without the es- 
sential implication of the other categories of mental facul- 
ties. Again, there may be conceptions which, though not 
false, are yet abnormal. 

INTELLECTUAL MONOMANIA. 

A perversion of the intellect characterized by the exist- 
ence of delusions limited to a single subject or to a small class 
of subjects. 

Two forms of this affection are met with. In the one there 
is mental exaltation, in the other there is mental depression. 

a — INTELLECTUAL MONOMANIA WITH EXALTATION. 

Although the most prominent symptoms of intellectual 
monomania with exaltation may appear with suddenness, 
there is almost always a characteristic prodromatic stage, 
marked by very decided evidences of mental aberration. 
These usually consist of erroneous conceptions relative to the 
importance of the affected individual, the attention which 
others show him, the observation he attracts as he walks the 
street or enters a room, the unfitness of a man of his parts 
for the perhaps humble occupation he follows, and the dispo- 
sition he evinces to talk about his many superior accomplish- 
ments or bodily perfections. Gradually these become so pro- 
nounced that they attract the attention of those with whom 
he comes in contact ; but, as he continues to transact his 
business properly, and behaves himself well in other respects, 



INTELLECTUAL MONOMANIA WITH EXALTATION. 329 

his condition is rarely, by the superficial observer, regarded 
as being one of incipient insanity. It is usually supposed at 
first that what he says of himself is simply an exaggerated 
style of speaking, and it is remarked of him that he is be- 
coming vain, and otherwise disagreeable. The physician, 
however, meeting with such a case, will scarcely fail to see 
that the change of character, or the abnormal development of 
traits, which previously existed only in light degree, is one 
of the strongest and most common manifestations of mental 
derangement. 

With these symptoms connected with the mind, there are 
others of a physical character. There is almost always in- 
somnia, there is sometimes pain or discomfort in the head, 
there is excessive motility and restlessness, the bowels are 
constipated, the skin is dry, the eyes are brighter than usual, 
the speech is hurried, but there is no incoherence of either 
words or ideas. 

Gradually the mental symptoms develop in intensity and 
definiteness, and one or more delusions become firmly estab- 
lished. They may be based on illusions or hallucinations, or 
they may arise from purely imaginary premises not connected 
with the senses. Sometimes they are spontaneous, and at 
others they appear to come from dreams. In a former chap- 
ter I have adduced several examples of delusions obviously 
the result of strong mental impressions made by dreams. 

As instances of the existence of perceptional derangement 
before the occurrence of delusions of fixed character, and ap- 
parently leading logically to the intellectual derangement, I 
cite the following from my note-books : 

The patient, a master plumber, had for several weeks been 
a little excited in his manner, and disposed to exaggerate his 
importance as a plumber, contending, with great earnestness, 
that no one understood the business as well as he did. He 
had cards printed, announcing himself as having more prac- 
tical experience than any other plumber in the United States, 
and that his work could not be excelled, as he had devised 
new methods of soldering which absolutely did away with 
all possibility of leaks. He had a large business, and it was 
known that he had been experimenting with solders, so that, 
though his statements were regarded as extravagant, they 
were not looked upon as much more than smart advertising 
devices. 



330 DESCRIPTION AND TREATMENT OF INSANITY. 

But one morning he announced to his wife that he had 
received a communication from a deceased plumber, by which 
he was informed of a still greater improvement to be made in 
soldering and in the manufacture of lead pipes. His story 
was that, while sitting in his shop reflecting on the best 
method of making lead pipes and solder,' he heard a whisper 
telling him to soak the lead in shark's blood and the solder 
in shark's urine, and that then neither could ever give way. 
Steamships, it was told him, could be made of large pipes 
soldered together. He expressed some surprise that he could 
not see the individual who spoke to him, and who, he said, 
called himself the "boss plumber of eternity"; but he did 
not attempt to account for the invisibility. He was promised 
by the voice a pre-eminence over all other plumbers, and a 
degree of wealth such as the most sanguine member of the 
craft never dreamed it possible to obtain. 

All this put him into a state of the greatest good humor. 
His face wore a continual smile ; he talked to every one he 
met of his great luck, and he joked about the envy of the 
other plumbers, and of the attempts they would doubtless 
make to rob him of the honor and profit to accrue to him. 
As he did no harm to anybody, and as he was perfectly will- 
ing to let his son attend to his real business while he worked 
at his experiments, he was not confined in an asylum. Finally 
he became less exact in his delusion ; he began to be ram- 
bling and incoherent, and is now, after over ten years' dura- 
tion of his insanity, in a condition of chronic mania approach- 
ing dementia. 

In another case, that of a young lady eighteen years of 
age, there had been for several weeks a slight degree of men- 
tal excitement, which was attributed to suppressed menstrua- 
tion. But there were no marked signs of insanity till she 
announced to her mother that angels had been whispering to 
her all night that the Virgin Mary would soon pay her a visit, 
and that she must be prepared to receive her august guest 
with due honor. From that time she became greatly impressed 
with a sense of her own dignity, and insisted on writing let- 
ters to the cardinal and to several bishops, inviting them to be 
present on the occasion of the visit. The time for this was 
not fixed ; she was informed by the angels that she must be 
"always ready," for, as " Christ would come as a thief in the 
night, so would his mother." She therefore always kept her- 



INTELLECTUAL MONOMANIA WITH EXALTATION. 331 

self, as much as her friends would allow, in full dress, and 
even went to bed with all the jewellery on her person that she 
could collect, and with a gorgeously decorated silk dress by 
the side of her bed, ready to be slipped on at the least warn- 
ing that the virgin was coming. She recovered in a few 
months, and has remained well. 

Even when illusions or hallucinations are not among the 
first symptoms, very few cases of the affection in question 
run their course without sensorial aberrations. Occasionally, 
however, this is the case. In a patient under my own charge, 
who imagined himself to be Charles XII of Sweden, and who 
strutted about with all the finery he could gather together, 
fastened in the most incongruous manner to various parts of 
his person, there were no illusions or hallucinations of any of 
the senses, so far as could be discovered. In the following 
case, which I take from Dr. Parsons's records, the like condi- 
tion apparently existed : 

E. H., female, thirty-six years old, a native of France, and 
by occupation a "clairvoyant," says that Louis Napoleon 
was her father, and Antoinetta, a daughter of Queen Yictoria, 
her mother. Has known that she was Napoleon's daughter 
since she was four years old, but said nothing about it till 
about a year ago. Got into some trouble in Pittsburg, and 
threatened to have the mayor deposed if he did not attend to 
his business. Came to New York to get her rights. A hun- 
dred thousand dollars are due her. Says all the shopkeepers 
in New York ought to make her presents ; says the sun and 
the moon come down and walk with her, but seems to mean 
by this that they shine on her in a peculiar way in honor of 
her nobility. 

As the delusions in monomania with exaltation usually re- 
late to the greatness, the honor, the wealth, the beauty, or 
some other ennobling quality or desirable condition of the in- 
dividual, the bearing and attitude of the patient are in log- 
ical accordance therewith, though at the same time are car- 
ried to such an extreme point as to show the most decided 
aberration of judgment. The individual, for instance, who 
imagines himself to be an emperor, and who stalks about in 
the most pompous manner, his head thrown far back, his 
lips compressed, and his eyes expressing the sense of his 
grandeur, not only overacts his part in these directions, but 
renders himself still more ridiculous with a piece of tin on 



332 DESCRIPTION AND TREATMENT OF INSANITY. 

his head for a crown, a cane for a sceptre, a rush-bottomed 
chair for a throne, and bits of tawdry finery pinned to his 
coat to represent the orders he is entitled to wear. 

u In ambitious monomania," says Marce, 1 "the patient de- 
clares that he comes of an illustrious ancestry ; he invents a 
history of himself and family which excites wonder by the 
minutiae and precision of its details. He speaks of his edu- 
cation and of his surroundings, and brings together, in har- 
mony with his ideas, all the persons and incidents which he 
can imagine. He wearies the authorities with his demands, 
and finally, when placed in an asylum, he never ceases to pro- 
test against what he considers to be his arbitrary detention, 
and the outrage of which he is the victim." 

A colored man, as black as a bit of charcoal, had the de- 
lusion that he was white, and that he was " King of the North 
Pole." He fastened a lot of metallic labels from sardine-boxes 
together, and wore them for a coronet, while a pair of old 
epaulets dangled from his coat-tails. The gait, the pose, the 
expression of these people, are often sufficient of themselves 
to indicate the general character of the delusions they en- 
tertain. 

Some forms of religious monomania, as it is called, and 
others of erotomania, in which there are delusions of an ex- 
alted character, are to be embraced under the present head. 
In the one, the patient, if a man, imagines that he is God or 
Christ, or some noted prophet or saint, or that he has a spe- 
cial mission from the Almighty to declare his purposes to 
mankind. If a woman, she may consider herself to be the 
Virgin Mary, or the " bride of Christ," or about to give birth 
to a second son of God. Such cases in either sex are em- 
braced under the term " theomania," and they include some 
of the most remarkable to be met with in the annals of in- 
sanity. 

Thus, there is the instance of Joanna Southcote, an igno- 
rant woman, who, some eighty years ago, persuaded a large 
number of persons that Christ was to be born again of her, 
and that he was his own father. She called herself the 
Bride, the Lamb's wife, clothed with the sun. Day and 
night she had hallucinations or visions, as she called them, 
which she accepted as realities, and which formed the basis 
of her prophecies and system of religion. Meetings were held 

1 "Traite pratique des maladies mentales," Paris, 1862, p. 365. 



INTELLECTUAL MONOMANIA WITH EXALTATION. 333 

to inquire into the truth of her pretensions, and, a court of in- 
vestigation being organized, she was accepted for all she as- 
sumed to be. Among others of her hallucinations was one 
that Christ had occupied the same bed with her, and that she 
had seen and conversed with him. Such sexual orgasms were 
frequently misinterpreted by the mystical women of the mid- 
dle ages into acts of intercourse with angels and members of 
the Godhead, so that Joanna's experience was not isolated. 

In her sixty-fifth year she gave out that she was pregnant, 
and that Christ would soon be born again. She was exam- 
ined by several medical men, who certified that she was actu- 
ally pregnant. A crib was procured, which, with the elabo- 
rate bedding, cost over two hundred pounds, but which was 
nevertheless called a manger. The faithful waited in vain 
for the heavenly infant, but excuses were made, and she con- 
tinued to have followers till her death, several years after- 
ward. 

A somewhat similar case has occurred in my own experi- 
ence, in which the patient, the wife of a stone mason, fancied 
that she was pregnant by the Holy Ghost, and that she was 
about to give birth to a second Christ, who was to revolu- 
tionize the world. As a matter of fact, she was pregnant. 
She insisted that the child left her womb every night, and 
conversed with her relative to the wonderful things he was 
going to do when he had accomplished the full term of his 
intrauterine life. Under the head of " Epidemic Mania" the 
subject in some of its relations will receive further consider- 
ation. 

In erotomania of the intellectual variety there are de- 
lusions in which the subjects imagine either that their per- 
sonality is changed, and that they are enacting the part of 
some noted historical individual, whose life was full of ro- 
mantic episodes, or that they were and are violently beloved 
by a real personage, whom they consequently annoy with 
their importunities. The case of a young lady occurs to me 
in this connection who had the delusion that her hand had 
been requested in marriage by a distinguished statesman, and 
whom she continually annoyed with letters asking for inter- 
views, and begging that a day might be fixed for their mar- 
riage. Subsequently, she had the hallucination that he had 
passed the night with her in a hotel in Jersey City, and, 
as she talked freely of the supposed circumstance, trouble 



334 DESCRIPTION AND TREATMENT OF INSANITY. 

would have been caused but for the fact that the gentleman 
was able to show that he was in California for several weeks 
before and after the alleged seduction. She was taken to Eu- 
rope by her father and placed in a lunatic asylum in Ger- 
many, where she still remains. 

Though not generally disposed to do serious mischief, the 
subjects of monomania with exaltation are always ready to 
defend their imaginary rights, and to quarrel with those who 
dispute their claims to distinction. Hence, they are more or 
less troublesome and offensive to those with whom they come 
in contact. A word, however, in recognition of the truth of 
their delusions, generally suffices to restore them to equa- 
nimity. A not uncommon form of the affection is that in 
which the delusions relate to some wonderful or useful dis- 
covery or invention which the patient imagines he has made. 
One thinks he has devised a machine for converting water 
into wine. According to him, it is only necessary to pour the 
water into a receptacle attached to the apparatus, and to 
turn a crank, when wine of the best quality flows out of a 
spout at the other end. Another conceives that he has dis- 
covered a powder which, when administered to women, will 
cause them to fall in love with the giver. The following re- 
markable instance I take from the New York Tribune of 
July 2, 1880 : 

A man had the delusion that lead would float on the sur- 
face of water, and his faith in his false belief led to his 
death. For several days he had been acting very strangely, 
when suddenly he disappeared. Before doing so, however, 
he sent a letter to his wife to this effect : 

" My deae Wife : I have finally struck something which 
will bring in money, and I hope happiness, to all of us. I 
have invented a life-preserver, on an entirely new principle, 
and am so sanguine as to its results that I am going to try it 
to-night. I find that it is a fallacy that cork or any wood that 
absorbs water is lighter than lead. Lead does not displace 
as much water, but, when submerged, I find that it has three 
times the lifting power of cork. I have got some lead cut in 
strips three quarters of an inch wide, and can make a jacket 
of it, for two dollars and a half, that any one can float in for 
days and days. Everybody has always said that, because 
lead was in air heavier than cork, it would be in water ; but I 
have three times tried it, and find lead in water will, in pro- 



INTELLECTUAL MONOMANIA WITH EXALTATION. 335 

portion to its weight, float ten times its weight in cork. Cork 
costs fifty cents a pound, lead six cents, and I can pnt life- 
preservers on all boats, ships, and steamboats in the world at 
half price. I am sure of a hundred thousand dollars to-mor- 
row. I have everything ready for the trial. I will go out to- 
night on a Goodrich steamer, and I will be back at 9 A. m., 
and show everybody that they can make lead float as well or 
better than cork. The result will be that when I come home 
to-morrow I can sell the right for one hundred thousand dol- 
lars, and get rid of all the trouble I am in. I will leave my 
clothes in the boat — watch, money, etc. — for fear I may have 
the lake to cross ; but the way the wind looks now, I can get 
home by 12 m. As I shall not go more than forty miles out, 
and if the wind is right, with my armor I can get in in two 
hours. I will get rid of my debts, and fit you and the chil- 
dren out nicely on what I can get when I get in town to-mor- 
row. Don't worry." 

The poor man had made either a life-preserver or a jacket 
of lead, and had jumped overboard from the steamer into the 
water, expecting to float on the surface for hours or days 
till he could be rescued. 

The delusions of intellectual monomania with exaltation 
sometimes relate to a change of sex which the individual 
supposes to have taken place in his or her organization, and 
which is regarded with great pride and satisfaction. In these 
cases, the manners, customs, and dress of the sex into which 
they imagine themselves to be changed are assumed, and their 
actions are regulated as nearly as possible in accordance with 
the erroneous belief. These cases are not to be confounded 
with those which, occurring in males, are due to injury pur- 
posely inflicted on the generative organs, and to which I have 
called attention in a recently published memoir. 1 They are 
instances of true monomania, characterized by the existence 
of delusions, which the others are not, and may exist either in 
males or females. In those which have come under my ob- 
servation there was no degeneration or exaltation of the sex- 
ual feeling, the subjects behaving not only with perfect de- 
corum, but with excessive modesty. 

In one of these, the patient, a young man of good family 
and finished education, but with a strong hereditary tendency 

1 " The Disease of the Scythians and Certain Analogous Conditions," Ameri- 
can Journal of Neurology and Psychiatry, August, 1882. 



330 DESCRIPTION AND TREATMENT OF INSANITY. 

to insanity on his mother's side, obtained the idea that he 
had become a woman, from seeing, as he imagined, his own 
image looking like a woman, and in the dress of the female 
sex. At the same moment a voice said to him, "Go thon 
and do likewise " ; and this was repeated to him many times 
during the day. Without at the time believing that his sex 
was changed, he put on woman's apparel, and remained in his 
room all day, surveying himself in the glass with great satis- 
faction, and walking up and down the floor, aping the gait 
and attitudes of the other sex. Little by little, however, the 
idea that his sex was changed took possession of him, and 
he came to me for an examination, which he was confident 
would confirm him in his belief. He was somewhat sur- 
prised to find that my opinion was different from his own, but 
no demonstration sufficed to shake him in the strength of his 
conviction. He congratulated himself that, being a woman, 
his emotional nature, which, as he said, had up to that time 
been very coarse and undeveloped, would now be delicate and 
refined. 

A man, named Binns, died recently in the Philadelphia 
Almshouse, at the age of sixty-nine years, who had for a long 
time been a notorious character in that institution, in conse- 
quence of entertaining the delusion that he was a woman. 
He affected woman' s ways, and was known by the name of 
" Sally Binns." When a young man, he had joined a theatri- 
cal club as an amateur, and the height of his ambition was to 
play female characters. He became a monomaniac on this 
subject, his infatuation at last took upon itself a mild form 
of insanity, and for the greater part of his life he entertained 
the belief in question. At all times, and on all occasions, he 
believed himself to be a dashing beauty, at whose feet scores 
of ardent admirers knelt, and upon whom society smiled with 
favor. Clad in feminine attire, whenever a ball or concert 
was given for the patients he was the centre of attraction. 
He affected an effeminate voice in conversation, and acted in 
every respect like one of the female sex. The air of a woman 
never deserted him, and everybody who visited the Alms- 
house called on " Sally." 

The late Dr. James R. Wood informed me that he had 
several years ago observed the case of a young woman who, 
without any exaggeration of the sexual feeling, imagined her- 
self to be a man, and who dressed herself, whenever she could 



INTELLECTUAL MONOMANIA WITH EXALTATION. 337 

do so without being prevented, in men's clothing. It was a 
veritable delusion, and not one of those cases in which the in- 
dividual, while having no delusion of a change of gender, 
evinces erotic propensities toward members of his or her sex. 
Delusions of this character are sometimes, as in the instance 
first mentioned, preceded and accompanied by hallucinations, 
but usually there is no sensorial aberration. In Dr. Wood's 
case the woman admitted that she had the breasts and the 
genital organs of a member of the female sex, but she con- 
tended that these were not true marks of sexual difference, 
which were really to be found in a certain organ or part of 
the brain. She insisted that she knew of several persons 
who, though having the sexual organs common to women, 
were in reality men. She had an idea that all unfruitful 
women were really men, and that all men with blue eyes and 
light hair were women. 

Again, the delusions of the intellectual monomaniac may 
relate to changes which he supposes have taken place in 
various parts of his body. One believes that his hand is 
made of glass, and he carries it enclosed in a stout leathern 
case to prevent its being broken by contact with other sub- 
stances. Another imagines that his teeth are of pearls, and 
he struts about, in the most bombastic manner, with open 
mouth, descanting on the beauty and value of its contents, or 
with his lips tightly closed, for fear some one may rob him of 
his treasures. And another believes herself to be endowed 
with such a supernatural degree of procreative power that 
she becomes spontaneously impregnated, and is delivered of a 
child every night, which is at once taken to an emperor's pal- 
ace and brought up as a prince of the imperial blood. On 
all other subjects than those directly connected with these 
delusions, intellectual monomaniacs reason with such a de- 
gree of lucidity as readily to pass for sane persons with most 
observers, and often even with skilled physicians. As Guis- 
lain 1 says, they preserve more or less fully the appearance 
and manners of normally constituted individuals ; the mem- 
ory remains intact, they retain their knowledge of arithmetic, 
they know how to distinguish that which is right from that 
which is wrong, they judge correctly of passing events, and 
they can, up to a certain point, conduct themselves well in 
the world, and even sometimes manage their own business 

1 "Lecons orales sur les phrenopathies," etc., Paris, 1880, t. i, p. 229. 
22 



333 DESCRIPTION" AND TREATMENT OF INSANITY. 

matters with promptness and discretion. Moreover, it may 
be added that they very often have the power, especially in 
the earlier stages of the malady, before the mind becomes 
markedly enfeebled, of concealing their delusions nnder the 
most rigid examination. But, while able to perceive the lu- 
dicrous character of the delusions of their fellow-lunatics, 
they cling tenaciously to their own, which are, perhaps, still'- 
more ridiculous. " Look at that poor woman," said a gentle- 
man to me as we walked together through the grounds of an 
asylum ; " she has lost her baby, and she thinks she has it in 
that bundle of rags she is nursing." Yet he was himself 
under the delusion that he was General Grant. 

As we have seen, the form of mental derangement under 
notice may be unaccompanied by illusions or hallucinations. 
Even when the existing delusion is of such a character as 
apparently to be connected with some one of the senses, and 
thus to be based upon a false perception, full inquiry will 
often show that there is no error of the sensorial processes, 
centric or eccentric. Thus, a lady under my care had the de- 
lusion that she had lost her palate. I held a mirror to her 
face, and, while she opened her mouth, I pointed out to her 
that all the parts were present. "Yes," she replied, "I see 
all that ; the form is there, I know very well, but the sub- 
stance is gone," and no arguments could convince her to the 
contrary. A gentleman conceived that his right hand was 
made of glass, and, therefore, to prevent its being broken, he 
kept it carefully enclosed in a stout case, made to fit it ac- 
curately. On my calling his attention to the physical quali- 
ties of his hand, and pointing out how they differed from 
those of glass, he said : "I once thought just as you do. My 
brain was then incapable of appreciating minute differences 
as well as it can now ; and though I confess that my senses 
still convey to me the idea that my hand is like other people' s, 
yet I know that the conception is erroneous, and I correct it 
at once by my reason. My hand looks like flesh and blood, 
but it is glass for all that. Nothing is more calculated to de- 
ceive than the senses." On my asking another monomaniac, 
who believed that she was the Princess of Wales, whether 
she thought her prototype would be seen walking about in a 
pink muslin frock, trimmed with copper wire, from which 
dangled buttons of various shapes and sizes, she replied : 
" Certainly not ; when I lived in England I was at court, 



INTELLECTUAL MONOMANIA WITH EXALTATION. 339 

and I was obliged to wear my grandest jewels ; bnt in this re- 
publican country I am not allowed to dress as I would like, 
and hence I put on these symbols. The copper wire stands 
for gold cord, and the buttons for diamonds and pearls." 

Remissions are not very common in intellectual mono- 
mania with exaltation, and intermissions are still rarer. Oc- 
casionally the patient may hold to his delusions with less 
tenacity than at other times ; he may even express some 
doubt as to their reality, but such manifestations are of short 
duration, and it is quite certain that often he is not sincere in 
his declarations, having some object in view which he thinks 
he may gain by dissimulation. As Haslam * says : 

" They have sometimes such a high degree of control over 
their minds that, when they have any particular purpose to 
carry, they will affect to renounce their opinions, which shall 
have been judged inconsistent, and it is well known that they 
have often dissembled their resentment until a favorable op- 
portunity has occurred of gratifying their revenge. Of this 
restraint, which madmen have sometimes the power of im- 
posing on their opinions, the remark has been so frequent that 
those who are more immediately about their persons have 
termed it, in their rude phrase, ' stifling their disorder."' 

During the course of intellectual monomania with exal- 
tation there may be intercurrent attacks of extreme excite- 
ment, during which there is active delirium, characterized 
by great volubility, incoherence, and excessive motility. At 
such times the patient may become combative, not only in 
defence of his delusions, but offensively. There is usually 
at these periods slight febrile exacerbation, and the sleep is 
disturbed more than ordinarily. These paroxysms become 
less frequent as the disease advances, until finally they no 
longer occur. Under the head of " Scheming Insanity," Ar- 
nold, 3 a hundred years ago, described a form of mental de- 
rangement which is embraced within the limits of intellectual 
monomania with exaltation. 

"The patient," he says, " thinks himself either endowed 
with better natural talents, and with more penetration and 
sagacity, or improved with greater acquisitions of knowledge 
and experience, or more enlightened by the special favor of 

1 " Observations on Madness," etc., London, 1809, p. 53. 

2 " Observations on the Nature, Kinds, Causes, and Prevention of Insanity," 
second edition, London, 1806, p. 170. First edition published in 1782. 



340 DESCRIPTION AND TREATMENT OF INSANITY. 

Heaven, or more secure of success by the happy concurrence 
of power, interest, opportunity, or some other advantageous 
circumstance, than most other men, and, either by his supe- 
rior knowledge or cunning, capable of doing great things, 
which few or none but himself are able to accomplish ; or at 
least feels an irresistible inclination to be engaged in some 
schemes or traffic ; and, as he thinks himself, if not actually 
the most knowing, at least among the most knowing of man- 
kind, so he is secure of that success which the simple and 
ignorant may wish for, but the wise and provident alone can 
command." 

Many cases of the monomania of Esquirol, and the me- 
galomania of Dagonet and others, are also comprehended 
under the head of intellectual monomania with exaltation. 

b— Intellectual Monomania with Depeession. 

This mental disorder is not to be confounded with the 
emotional form of insanity known as lypemania, or melan- 
cholia, with which, though entirely distinct, it has naturally 
many relations. It is the monomanie triste of Marce, and, 
as this author has pointed out, is characterized by the fact 
that, although the patient has fixed delusions of a melan- 
cholic character which influence him in his actions, he can, 
nevertheless, reason well in regard to other subjects, and is 
often able to conduct himself with entire propriety in all the 
relations of life, outside of his own particular erroneous be- 
liefs. In melancholia, on the other hand, the emotions are 
involved to an extreme degree ; the false conceptions assume 
entire control of the mind and render the individual alto- 
gether incapable of the systematic performance of rational 
acts, whether they are or are not connected with his delusions. 

Like the preceding affection, intellectual monomania with 
depression may arise suddenly, or may be preceded by pro- 
dromatic symptoms. These latter, instead of being of the 
expansive character peculiar to intellectual monomania with 
exaltation, are depressing in their nature, and hence present 
an entirely different ensemble from that met with in the other 
form of the disorder. Usually they consist of ill- defined 
ideas that people are conspiring against the person in whom 
they exist. He accordingly becomes suspicious of those about 
him, looks around uneasily, watches every movement in 
others, takes unusual means to protect himself from imagi- 



INTELLECTUAL MONOMANIA WITH DEPRESSION. 341 

nary attacks upon his person or property, imagines that con- 
versations which occur in his presence, and which he does 
not hear, relate to him and to plans for injuring him in various 
ways. He conceives the idea that his Mends and relatives 
are wanting in proper respect for him, that he is neglected by 
them and by his servants, and, if he is sufficiently ignorant, 
that certain persons have laid a spell on him or bewitched 
him. A patient from the interior of this State, who consulted 
me a short time since, had the notion that his wife one morn- 
ing had looked at him in a peculiar way, and that instantly 
he felt a thrilling sensation pass through his brain. He was 
also under the impression that, being jealous, she had en- 
deavored to render him impotent, in order that a condition of 
forced faithfulness might be induced. As he walked the 
streets, he conceived that the people he met, not one of whom 
did he know, looked at him as if they were aware of the fact 
that he was deprived of virile power. He had not been in the 
city longer than a few days when he contracted the delusion 
that his testicles had disappeared, and this was followed by the 
idea that he had been castrated by order of the Pope, in order 
that he might be put in the choir at St. Peter's in Rome. 

The most singular fact connected with the case was that 
his sexual powers were unusually strong for a man of his age, 
and that he had intercourse, on an average, once in twenty- 
four hours during the whole time that he was under my ob- 
servation — a period of ten days. 

Illusions and hallucinations may be present at a very early 
period, and these very generally relate to the sense of hear- 
ing, though by no means exclusively. In a case that came to 
my clinique at the University Medical College several years 
ago, the patient, a man of adult age, had imbibed the delu- 
sion that people were endeavoring to poison him with noxious 
vapors, and this idea had clearly arisen in consequence of 
the long-continued presence of a hallucination of the sense of 
smell. I have also seen several cases in which illusions of 
taste have given rise to similar delusions. 

Sometimes the apprehensions of impending evil which the 
individual experiences are vague and indefinable. He feels 
that something is going to happen, but what, he does not 
know, and often an accidental circumstance gives form to the 
fears which he entertains. 

Thus, a young man employed in a counting-house had 



342 DESCRIPTION AND TREATMENT OF INSANITY. 

been for several weeks tormented with morbid fancies of some 
great catastrophe being about to occur by which he and all 
his friends would be destroyed. He was unable to sleep with 
comfort, or to procure a sufficient amount, for, as soon as he 
got to sleep, he was awakened by some terrible vision, and 
Avould often spring from the bed in his terror and rush into 
his father's room imploring protection. 

During all this period he continued to attend at his place 
of business, and to perform the duties required of him. One 
morning, however, soon after taking his seat at his desk, a 
stranger entered the room, and, inquiring his name, occupa- 
tion, and residence, proceeded to record the items in a book, 
and soon afterward took his departure. At once the idea took 
possession of the young man's mind that the stranger was a 
detective, sent to obtain information preparatory to making 
his arrest on the charge of murder, and to this conception 
the fact that the stranger had said something about a dead 
man contributed in no small degree. The man was in reality 
an agent for the publishers of a directory ; but this fact could 
not be made clear to the patient, and the delusion that he was 
" wanted" on the charge of murder took full possession of 
him. He consequently locked himself up in his room, and 
refused to come out for any purpose whatever. At last, how- 
ever, he sent a notice to a newspaper announcing his death, and 
this appeared to relieve his apprehensions to such an extent 
that he left his room and walked about the house, and, even 
after nightfall, took a little exercise in the open air. But ere 
long his fears were renewed, delusions of persecution became 
firmly established, and it was necessary to send him to an 
asylum in order to prevent suicide or homicide, both of 
which he gave signs of contemplating. 

In another case the patient, a married lady, thirty years of 
age, had for several weeks experienced an indefinable dread 
for which she could assign no adequate cause. Her sleep be- 
came disturbed, her appetite capricious, her bowels consti- 
pated, and there were frequent sharp pains in various parts 
of the head. Her temper, which previously was remarkably 
mild and equable, was now irritable and fretful. The least 
thing was sufficient to derange her equanimity and to cause 
her to indulge in invectives and complaints to a degree that 
rendered her a very troublesome inmate of the house in which 
she resided. 



INTELLECTUAL MONOMANIA WITH DEPRESSION. 343 

But the most prominent symptoms were those connected 
with the fear that something terrible was abont to happen. 
This delusion took such a firm hold of her mind that she 
passed the greater part of her time when alone in weeping 
and wringing her hands, though, when some noted occasion, 
such as receiving visits or taking her meals in presence of 
others, required her to restrain herself, no one could be more 
composed. Things went on in this way for several weeks, till 
one day, as she was drinking her coffee at breakfast, she sud- 
denly exclaimed that it was poisoned, and, throwing the cup 
on the floor in her fright and agitation, she refused to eat any- 
thing more. From this time on, the idea that poison would be 
administered to her became a fixed delusion, which was often 
accompanied by illusions and hallucinations of taste, hearing, 
and sight. 

In both these cases there was present a condition which 
has attracted a good deal of attention from alienists, and 
which is one of the most important in all its relations of the 
several phases of the form of insanity under consideration, 
and that is the delirium of persecution. 

Generally this state begins with illusions and hallucina- 
tions which for a time may be strenuously resisted by the 
individual, but which usually end by obtaining a complete 
mastery over his reason. The sense of hearing is that which 
is generally the root of these false perceptions, which appear 
either as vague, uncertain sounds, or isolated words, or as 
well-defined sentences. These are in the form of threats or 
warnings, or advice as to the best way of escaping from im- 
aginary enemies or dangers. The sense of sight is not so fre- 
quently affected, though occasionally the patient sees a po- 
liceman or other person in seach of him in every one who 
looks at him a little closely. In order to escape from these 
imaginary enemies he makes complaint to the officials, or seeks 
safety in flight, or may even proceed to the extent of perpe- 
trating suicide or homicide. Sometimes the individual labors 
under the delusion that organized bodies of men have banded 
together for the purpose of destroying him, or of inflicting 
severe bodily injury upon him. These may, in his imagina- 
tion, be the whole police force, or the clergy, or the medical 
profession, or the masonic fraternity, or the members of some 
nationality. A patient of mine was sure that all the clergy- 
men had entered into a conspiracy to " pray him into hell." 



3±± DESCRIPTION AND TREATMENT OF INSANITY. 

He went to the churches to hear what they had to say, and 
discovered adroit allusions to himself, and hidden invocations 
to God for his eternal damnation in the most harmless and 
platitudinous expressions. He wrote letters to various pastors 
of churches denouncing them for their uncharitable conduct 
toward him, and threatening them with bodily damage if 
they persisted in their efforts to secure the destruction of his 
soul. 

Another was constantly dodging around the corners of the 
streets and hiding himself in doorways to avoid detectives, 
for whom he mistook all who happened to look at him with 
more than a passing glance, and who, he conceived, were 
seeking to arrest him on the charge of attempting to take the 
life of the mayor. U I never even saw the mayor," he would 
exclaim, with tears in his eyes, "and God knows I never 
wished him any harm, and yet these scoundrels are endeavor- 
ing to imprison me for shooting a pistol at him. There is an- 
other one of them ! " and instantly he darted down an area to 
hide till a bland-looking old gentleman, whom he took for a 
disguised detective, had passed. " That man," he continued, 
when he emerged from his place of seclusion, " is the sharp- 
est one of the whole lot. He looks seventy years old, but 
he's only twenty-five. His hair is a wig, and his beard is false. 
I can go nowhere without just managing to escape. Of course, 
he'll catch me at last, and then I shall go to prison for life." 

C. B., 1 after separating from her husband, and remaining 
absent six years, came to the United States from Ireland, and 
then married again. Shortly afterward a daughter by her 
first husband came over, and then the mother seemed to real- 
ize for the first time that she had two living husbands. This 
idea seemed to be the exciting cause of her insanity, which 
first showed itself in unfounded suspicions that her daughter 
was leading an improper life. Hallucinations of hearing next 
supervened, and these were that people were talking about 
her night and day. Heard a young man say that she was a 
bad woman, had stolen laces, committed forgeries, and was 
the mistress of a Mr. Welsh. Also heard him say that a 
play founded on her life was being performed at a theatre. 
Says that people look crossly at her, and point their fingers 
toward her. Is very positive about all she heard and saw, 
and says her opinion could not be changed if all the circum- 

1 From Dr. Parsons's MS. " Notes of Cases in JBlackwelPs Island Asylum." 



INTELLECTUAL MONOMANIA WITH DEPRESSION. 345 

stances should be denied by the persons who spoke about 
her and pointed at her. This patient remained in the asy- 
lum for several years in about the same condition as when she 
entered it. 

It is not at all uncommon for the victims of delusions of 
persecution to imagine that they are being acted upon by 
some occult influence, or by some one of the forces of nature, 
as heat, magnetism, or electricity. " Spells " are laid on them 
by certain individuals whom they know, or by invisible per- 
sons who only make themselves known by their speech. In 
one case that was under my charge, the patient, a stationer, 
doing business in this city, had the delusion that unknown 
enemies — freemasons — were acting on him by electricity, 
which they sent into his brain, through the top of his head, 
by powerful batteries which they had in their lodge-rooms. 
In another, a woman, who kept a small shop in the Bowery, 
and who came to my clinique at the Bellevue Hospital Medical 
College for the purpose of getting relief, conceived that all 
the iron railings and railway tracks had been charged with 
electricity in order to injure her, and that, whenever she 
touched one of them or even came near it, she received a 
severe shock. A case of like character is cited by Seme- 
laigne. ' 

Very slight causes are sometimes sufficient, in a patient 
suffering from intellectual monomania with depression, to 
excite hallucinations which have been for some time absent. 
Poterin du Motel 2 cites the case of a woman who had become 
melancholic, lost sleep, had pains in her head, and bleeding 
from the nose, in consequence of some ^significant family dis- 
agreement. She contracted the delusion that her sisters, who 
were in reality devoted to her, had conspired to injure her. 
Had also illusions and hallucinations. Saw a black head, and 
heard voices speaking against her. The mere opening or 
shutting of a door, a step on the floor, or the slightest sound, 
was sufficient to excite these hallucinations. 

A somewhat similar case was at one time under my obser- 
vation, in which the subject, a lady thirty years old, whose 
mother had died insane, and who was herself of a strongly 

1 "Du diagnostic et du traitement de la melancolie, 1 ' Memoires de Vacademie 
imperiale de medecine, t. xxv, p. 235. 

2 "Etudes sur la melancolie," etc., Memoires de Vacademie imperiale de 
medecine, t. xxi, p. 462. 



346 DESCRIPTION AND TREATMENT OF INSANITY. 

marked nervous temperament, suddenly became affected with 
hallucinations of hearing, by which she was told that her ser- 
vants had entered into a conspiracy to burn the house and 
her with it. Although she never had any hallucination of see- 
ing the persons from whom the noises were supposed to come, 
she was quite sure that they proceeded from real individuals, 
concealed in various parts of the house, or under the steps of 
the houses she passed in the street. Night and day, while 
awake, she heard the voices. Finally the continuity of the 
hallucinations ceased, but the delusion remained, and she 
was constantly watching her servants, frequently changing 
them, and invoking the aid of the police in order to ensure 
her safety. But if at any time she heard a very loud noise, 
such as the rumbling of a heavy wagon in the street, or the 
explosion of a blast, the hallucinations at once returned. 

Lasegue x states that he has never witnessed a case of de- 
lirium of persecution in a person under twenty-eight years of 
age, or over seventy. In an instance recently under my ob- 
servation, the patient, a male, had not reached the age of 
eighteen when well-marked symptoms of the condition in 
question made their appearance. He had the idea that the 
workmen employed with him in a paper factory were hatch- 
ing a conspiracy to poison him, and several times ran away 
from his home in order to escape from his imaginary danger. 
Finally it became necessary to confine him in a lunatic asy- 
lum. 

The hallucinations and delusions to which persons affected 
with intellectual monomania with depression are subject 
sometimes lead them to falsely accuse themselves of having 
perpetrated various crimes. Instances of the kind are con- 
stantly occurring, and are of much interest, not only from 
their medical but from their legal relations. Gradually the 
false beliefs which have become a part of their mentality pro- 
duce such a degree of remorse for the offences that are sup- 
posed to have been committed, or excite such a high sense of 
duty, or awaken a desire to be executed, so as to escape from 
a life of weariness, that the individual delivers himself up to 
justice, and makes a full and perfectly coherent confession of 
his guilt. 

In former times, many persons, who had not even been ob- 

1 " Du delire de persecution," Archives generales de medecine, fevrier, 1852, p. 
129. 



INTELLECTUAL MONOMANIA WITH DEPKESSION. 347 

jects of suspicion, were executed for sorcery, witchcraft, and 
analogous crimes, on no other evidence than that which they 
themselves supplied by confession. A man was brought to me, 
only a few weeks ago, to be treated for insanity, and who had 
prepared a carefully written statement to the effect that he 
had been the instigator of Gruiteau in his assassination of the 
President. He had left his home for the purpose of giving 
himself up to the authorities at Washington, but had been 
stopped by his friends. He talked very calmly and intelli- 
gently of his imaginary crime, and went into all the details of 
his interviews with G-uiteau with a surprising degree of mi- 
nuteness and consistency. And yet it was a matter of abso- 
lute certainty that he had never seen Guiteau, or been outside 
the limits of the small village in which he lived for over two 
years before the President was shot. He felt no great sorrow 
for what he supposed he had done, but was, he said, actuated 
by an exalted sense of the duty of a citizen to suffer the 
proper penalty for any crime he may have committed. He 
was sorry to be imprisoned, but it was his duty to suffer, and 
suffer he would. He was in great terror lest the people 
should find out what he had done and lynch him, and, accord- 
ingly, his great anxiety was to get to the protection of a jail 
as soon as possible. As the case was one in which there was 
no premonitory tendency to insanity, and had clearly arisen 
from excessive mental work, I gave a favorable prognosis, and 
advised his being treated at home. 

I saw another case in which the patient, a man, confessed 
to having wrecked several railway trains and caused the sacri- 
fice of many lives. He said that he had, among other like 
crimes, cut the beams of the railway bridge at Harlem, and 
that he kept them together by the mere force of his will till 
such time as he was ready to destroy a train. 

In the majority of such cases the insanity has existed for 
a long time, and the occurrence of a disaster or the perpe- 
tration of a crime is the exciting cause of the peculiar de- 
lusion which seizes on the patient. Continued thought in 
any one direction is liable to produce more or less mental dis- 
turbance in the minds of the sanest persons. Repeatedly 
telling the same lie eventually induces the liar himself to be- 
lieve in its truth. 

It is quite commonly the case in intellectual monomania 
with depression that the chief delusions which the patient ex- 



348 DESCRIPTION AND TREATMENT OF INSANITY. 

periences are connected with the idea of approaching pauper- 
ism. Although he may be in comfortable, or even affluent 
circumstances, he is quite sure he is on the high-road to beg- 
gary, and that his wife and children are about to become 
inmates of the almshouse. He is influenced by these erro- 
neous conceptions to such an extent that he denies himself 
and family the commonest necessaries of life, and sits by the 
hour moaning over the sad fate in store for him and those de- 
pendent upon him. While entertaining the delusions in 
question he continues to transact his business well, though 
perhaps with increased caution, and in all other respects ap- 
pears to be perfectly sane. Inquiry, however, will almost in- 
variably reveal the fact that he suffers more or less from the 
somatic symptoms already mentioned. 

As in intellectual monomania with exaltation, so in the 
depressant form of the disorder, religion is capable of giving 
a peculiar impress to the phenomena manifested. There are 
no delusions of being great prophets, or saints, or members of 
the Godhead, but there are convictions which are accepted as 
absolute truths, that some great sin has been committed for 
which continual prayer must be offered, or that the offence 
has been so great that not even this remedy is effectual. I 
have already alluded to the delusion of the " unpardonable 
sin," and have cited one of the cases that have come under my 
notice in which it was the predominating feature. The fol- 
lowing is interesting in this connection : Several years ago a 
young man was brought to me by his father for examination. 
The moment he entered the room he fell on his knees before 
me, and, with clasped hands, implored my intercession with 
God for his forgiveness. It seems that he took me for a 
bishop. He entertained the delusion that he had committed 
thousands of heinous sins, and that his eternal punishment 
was not only assured, but was deserved. Nevertheless, it was 
his duty to pray. He had several times attempted suicide. 
I advised his committal to an asylum, and he was taken to 
Sanford Hall, at Flushing. As soon as he entered the parlor 
of the establishment, and before any of the attendants were 
aware of his purpose, he plunged his naked hand into the 
midst of a glowing anthracite fire in the grate, and would 
have held it there till it was entirely consumed but that he 
was instantly seized and dragged away. He did this as an 
act of atonement. But, while entertaining the belief men- 



INTELLECTUAL MONOMANIA WITH DEPRESSION. 349 

tioned, and making frequent attempts at bodily injury and 
destruction, there was not the lamentation and supreme un- 
happiness which would naturally have resulted in a sane per- 
son had his imaginary condition been a reality, or such as 
would have been experienced in some forms of emotional 
monomania or of acute melancholia. 

In regard to such cases Wachsmuth ' says : " It is not un- 
common to see these unfortunate people commit the most 
hurtful acts, not only against others, but often mutilations of 
their own bodies. They are well skilled in deception, and 
know how to elude the vigilance of their attendants. Not 
only do they torture themselves, cut their throats, swallow 
knives, nails, or whatever else will injure them, but they com- 
mit all kinds of violent and offensive actions against persons 
and things. To do wrong and to perpetrate crimes is in some 
manner a justification of the horrible accusations they bring 
against themselves. To humiliate themselves they must be 
abased in their own eyes and in the eyes of others. They 
must not only be full of wickedness, but they must show the 
world that they are wicked, and for this purpose they select 
as victims for their misdeeds those to whom they owe the 
most affection. The more infamous an action is, the more 
pleasure they take in its perpetration." 

Delusions connected with the relations of the sexes, and 
constituting a species of erotomania, are sometimes met with 
in intellectual monomania with depression. But, unlike 
those met with in the previously described form with ex- 
altation, they are of a sad or melancholic character. The 
subjects believe that they are persecuted by various per- 
sons who are endeavoring to prevent them making eligible 
marriages, or they imagine that they are being pursued by 
persons for whom they have no affection, and who are con- 
stantly watching them and seeking to entrap them so as to 
carry them off to some place where a violation will be com- 
mitted or a false marriage performed. In a case which I 
saw in August, 1882, with Dr. Leale, of this city, the patient, 
a single woman of about thirty-five years of age, had delu- 
sions of persecution of which those of an erotic character 
were prominent. In order to prevent the violation of her 
person, of which she imagined she was in continual danger, 
she not only went to bed in her day-clothes, but fastened 
1 " Pathologie der Seele," p. 98. 



350 DESCRIPTION AND TREATMENT OF INSANITY. 

her legs together with straps and napkins so as to give as 
much trouble as possible to the anticipated violator. A physi- 
cian, whose name has escaped me, informed me some time 
ago of a like instance occurring in his practice, and in which 
the patient had a tin case so constructed as to fit the perinseum 
and close the vulva, and which she fastened with lock and 
key whenever she went to bed. 

There is a species of intellectual monomania with depres- 
sion in which, while the delusions are of a sad character, 
there is little or no melancholy. This was, so far as I am 
aware, first described by Billod 3 under the name of "lype- 
mania with predominance of depressing ideas, but without 
reaction of sadness." It is, in fact, the purest of all the vari- 
eties of the form under notice, for it consists mainly of intel- 
lectual aberration with the minimum of emotional disturbance. 

As Billod ' says, the patient is neither sad nor gay. He 
seems indifferent to the ideas which have their seat in his 
mind, and he speaks of them without the least disturbance of 
his emotions. 

He gives the case of a lady who was not in the least mel- 
ancholic, although she was constantly giving utterance to the 
most disquieting ideas. Sometimes she imagined that her 
nose was growing, or was about to become detached from her 
face ; sometimes that her countenance was otherwise deformed, 
and sometimes believing that she was possessed of the elas- 
ticity of caoutchouc, she was afraid to take a step lest she 
should be bounced off into space. Then she imagined that 
she was affected with the most mortal and incurable of dis- 
eases. When expressing these ideas there was not the least 
emotion, and her countenance did not exhibit the slightest 
trace of sadness. Her indifference, in fact, was such that no 
one would have thought that she was speaking of herself. 

In another case the patient, a man, believed himself the 
victim of a society of demoniacs, and yet his equanimity of 
manner was not in the least disturbed. And another was 
constantly on the defensive against an imaginary enemy, 
whom he accused of inflicting a thousand tortures upon him 
— for example, abstracting from his body millions of kilo- 
grammes of blood, but who spoke of his misfortunes without 
exhibiting the slightest emotion. 

1 " Des diverges formes de lypemanie," " Annales medico-psychologiques," 
juillet, 1856; also, "Des maladies mentales," etc., Paris, 1882, t. i, p. 350. 



INTELLECTUAL MONOMANIA WITH DEPKESSION. 351 

I have had occasion to observe many such cases. In one 
very interesting instance the patient, a lady, who had some 
hereditary tendency to insanity, her grandmother on her 
mother's side having died in an asylum, had the delnsion that 
her hnsband was continually endeavoring to poison her. She 
watched everything on the table, and would eat or drink noth- 
ing till he had first partaken of it, and yet, while living in 
this constant apprehension of losing her life, she spoke of the 
matter with the most perfect unconcern. In all other respects 
she was, so far as I could ascertain, entirely free from mental 
aberration. She was fond of music, and went regularly to 
the opera ; she was a leader in several charitable and literary 
societies, and always conducted herself in public with the 
utmost decorum. Indeed, even at home there was neither 
disorderly conduct nor violent language, and no one but her 
husband was aware of the false belief which she entertained. 

"H ," she would say to him, while her face expressed 

no more interest than if she was talking of the most indiffer- 
ent subject, "you will never succeed in your horrible attempts 
so long as I possess my reason. I may lose my mind and be 
unable to watch you, and that is my greatest fear, but, so long 
as I preserve that, I will circumvent all your nefarious schemes. 
I saw you drop that powder into the soup-tureen before dinner, 
but I took it out as soon as you had sneaked out of the room. 
I heard you creep down stairs this morning to put your vile 
doses in the coffee-urn ; but if you are able to afford two or 
three makings of coffee every morning, I have no objection. 
Perhaps you will wear me out at last, and then you will put 
me in an asylum ; any keeper would poison me for five dol- 
lars. " Finally she became convinced that her husband thought 
her insane, and that he was making arrangements to place 
her in an asylum ; so one day she quietly secured passage, un- 
der an assumed name, in a steamer for Europe, and on the 
appointed day left her house as though she were going out 
for a morning's shopping, and, going aboard the vessel, took 
her departure for Liverpool. It was not known where she 
had gone till a letter was received from her, in which she 
stated her intention of returning as soon as she had paid a 
visit to Trouville and taken twenty-one sea baths. It was 
thought best by her friends not to interfere with her ; she 
took her twenty-one baths, and came back entirely cured. 
This was five or six years ago, and she is still in good mental 



352 DESCRIPTION AND TREATMENT OF INSANITY. 

health. The absence from all causes of excitement, especially 
from her husband, the change of air and scene, and the hy- 
gienic influence of the sea bathing, had effected a cure. In 
such cases it is difficult to say whether the delusion or the in- 
congruity between the false belief and the emotions consti- 
tutes the chief feature. It would almost seem as if there 
was, so to speak, a paralysis of the emotions, but examination 
shows that, as regards other ideas outside of the delusion 
which the patient may entertain, there is a normal degree of 
emotional activity. 

It is not at all uncommon for the subjects of intellectual 
monomania with depression to refuse all nourishment. This 
is generally the logical consequence of the delusions they en- 
tertain. For, believing as they often do that the food offered 
them is poisoned or is otherwise unfit for use, it is, of course, 
from their stand-point, a legitimate action for them to refuse 
to eat. Occasionally, however, they persist in not eating 
from a desire to die of starvation ; again, simply because they 
have no appetite, and, therefore, do not care to eat, and at times 
from a whim or a pure spirit of obstinacy. Again, the patient 
persists in remaining mute. A man who came to my clinique 
at the University several years ago refused to speak, but would 
write what he wanted to say. His reason was that he was 
surrounded by invisible enemies who could not see, but who 
were gifted with very acute powers of hearing, and that if he 
spoke, even in a whisper, they would know where he was 
and inflict bodily injury upon him. Sometimes it was said 
he would not even write, being convinced that several of his 
enemies, who were endowed with very acute powers of hear- 
ing, were listening with their ears on the paper so as to detect 
by the sound of the pen the thoughts he was expressing. 

Again, the delusion which actuates the patient may be of 
such a character as to urge him to refrain from doing other 
acts, the regular performance of which is essential to the well- 
being of the organism. Thus, a professor in a college, after 
passing through a period of great excitement, began to ex- 
hibit symptoms of insanity, and these soon took the form of 
intellectual monomania with depression. Among other delu- 
sions which he entertained was one that the kidneys were 
acting altogether- too freely, and that the phosphorus of his 
brain was being removed so rapidly as to bring him to the 
verge of idiocy. He talked of the matter with entire calm- 



INTELLECTUAL MONOMANIA WITH DEPKESSION. 353 

ness, but nevertheless took such measures as he thought 
would be effectual to arrest the elimination of the urine. He 
drank scarcely any fluid, and deferred the act of urination 
as long as was possible. Finally, nature, as he said, being 
too strong for him, he fastened a leather strap around the 
penis in such a way as to effectually prevent a drop of urine 
passing. For a whole day he endured, without complaint, 
the agony induced by this procedure. At last he began to 
groan, and to show other signs of extreme suffering, but, as 
none of those about him were aware of his act, and as he still 
refused to explain the cause, no intelligent efforts were made 
for his relief. The time came, however, when he could hold 
out no longer. He went into the closet for the purpose of re- 
moving the strap, and, being followed and watched, the na- 
ture of his torment was at once discovered. The penis had, 
however, become so swollen that the strap could scarcely be 
seen, and it was found to be impossible to unbuckle it. I saw 
him a few minutes afterward, and with great difficulty suc- 
ceeded in cutting the ligature. The urine dribbled out drop 
by drop, owing to the paralysis of the bladder from over- 
distention, but a catheter brought it away to the extent of 
nearly two quarts. He made a good recovery, but suffered 
for several months from paresis of the bladder. 

An interesting case is that of Jean Matthias Klug, 1 who 
had been Governor of the Department of Truchssee, and then 
secretary of a commission of the ministry of war in Prussia, 
and who was well skilled in the sciences of medicine, law, 
divinity, and physics. He was also acquainted with several 
ancient and modern languages, but, having written a book 
which contained religious sentiments contrary to those held by 
the King, or which he thought were of this character, lost his 
reason. He imagined that he had irritated his sovereign, and 
that orders had been given for his arrest and trial. He there- 
fore shut himself up with his nephew in an isolated house, 
strongly barricaded it, and never left it. His nephew dying, 
Klug put the corpse outside the door, with an inscription 
on it asking that it might be buried. He received his food 
through a grating. He wrote out his dreams, believing them 
to be inspirations. He died of apoplexy, at the age of 
sixty. 

1 " La folie consideree snr tout dans ses rapports avec la psychologie normale," 
etc., par J. Tissot, Paris, 1877, p. 268. 



354 DESCRIPTION AND TREATMENT OF INSANITY. 

Marce " states that in monomanie triste — which, so far as 
I can determine from his not very full description of the con- 
dition, does not differ essentially from that under consider- 
ation — the patients are prone to exhibit suicidal or homicidal 
tendencies. I do not think this view js correct, so far as 
suicide is concerned, though occasionally a proclivity to this 
act is shown. But, as regards other acts of violence, I think 
there can be no difference of opinion among alienists. Within 
a recent period several such cases have occurred in this city, 
one of which I had the opportunity of investigating. It was 
that of a Frenchman, named Dubourque, who, having for sev- 
eral years been affected with delusions of wrongs and injuries 
being done to him, and having made several assaults on per- 
sons whom he imagined had conspired against him, finally 
rushed through a crowded street, striking right and left with 
a pair of carpenter' s compasses at every woman he met. Some 
seven persons were stabbed by him, one of whom died. The 
only reason he could give me for his conduct was that "the 
women were talking about him." 2 As Marce further states, 
the affection is often transformed into melancholia, and it is 
then, doubtless, that the tendency to suicide is exhibited. 

The most common termination of both the forms of intel- 
lectual monomania which have been considered in the fore- 
going pages is chronic intellectual mania, and to that affec- 
tion the attention of the reader is now invited. 

C — CHRONIC INTELLECTUAL MANIA. 

By chronic intellectual mania is to be understood a con- 
dition in which there is a general disturbance of the intel- 
lect characterized by the existence of varying or non-sys- 
tematized delusions, and accompanied by periods of either 
mental excitement or depression, with more or less incohe- 
rence and mental weakness. It may arise protopathically, 
or may be the sequence of either of the affections just de- 
scribed, of an attack of acute mania, or of some other form of 
insanity. 

Under the head of chronic mania, asylum medical officers 
usually include every form of mental derangement the course 
of which is slow, or which they regard as permanent. The 

1 "Traite pratique des maladies mentales," Paris, 1862, p. 369. 

2 " A Case of Intellectual Monomania with Mental Depression," Illustrated 
Journal of Medicine and Surgery, April, 1883. 



CHRONIC INTELLECTUAL MANIA. 355 

present section is, however, to be regarded as restricted to the 
consideration of a mental disorder, the chief features of which 
are the presence of delusions, a defective power in the associ- 
ation of ideas, incoherence, and mental weakness. 

Chronic intellectual mania, as I have said, may show itself 
as a primary disorder. In such a case there is often a prodro- 
matic series of symptoms not essentially different from those 
met with in intellectual monomania. Thus, there are wakeful- 
ness, morbid dreams, illusions and hallucinations, and an un- 
natural state of mental and physical excitement, which, per- 
haps, of all the phenomena, most attracts the attention of the 
observer, and which may be present several weeks before the 
development of any marked degree of mental derangement. 

Thus, a young man, a salesman in a large mercantile house 
in this city, from having been rather slow in his movements 
both of mind and of body, and late in arriving at his office, 
suddenly exhibited a complete change in all these respects. 
He became remarkably assiduous in the performance of his 
duties, was the first to arrive in the morning, and seemed not 
only anxious to do his own work, but that of almost every 
other person in the establishment. During the day he was 
bustling about the rooms, packing and unpacking cases, ap- 
parently aimlessly running down into the cellar to see that 
the steam was all right, and giving orders to one and another 
as if the whole establishment belonged to him. For a while 
it was thought that all this activity proceeded from the fact 
that he had at last become aware of his deficiencies, and was 
striving, by an excess of zeal, to make amends for previous 
shortcomings ; but it was soon perceived that his show of work 
really amounted to nothing, and that his meddlesomeness 
caused only confusion and delay. At the same time it was 
noticed that his appearance was wild and haggard, and, upon 
inquiry, it was ascertained that he was irregular in his hours 
for coming home, that frequently he was out all night, and 
could give no clear or satisfactory account of his whereabouts. 
Before there were any other manifestations, his brother brought 
him to me and gave me the foregoing particulars. I also as- 
certained that he had suffered for several months with wake- 
fulness, and that hallucinations of sight and hearing had 
existed for a like period. These, however, he had kept to 
himself, and it was only with considerable difficulty that I 
succeeded in establishing the fact of their presence ; of their 



356 DESCRIPTION AND TREATMENT OF INSANITY. 

unreality lie was at this time fully aware, and lie attributed 
them to the circumstance of his not sleeping well. I could 
detect no evidence of the existence of delusions strictly so 
called, though there was certainly an idea in his mind that he 
was of great use to his employers, and that he did more work 
in the establishment than all the other salesmen combined. 
But on my asking him what he did that rendered him of so 
much importance he laughed, and replied that there was 
scarcely a thing about the house that he did not attend to. 
In reality this was not very far from the truth, so far as his 
intentions and efforts went. If he had been allowed to do as 
he pleased, nothing would have escaped him. I advised a 
residence for a month or two at some quiet place in the coun- 
try under the immediate care of a physician, the use of the 
bromide of sodium, and, as his bowels were obstinately con- 
stipated and the liver inactive — as they usually are in those 
cases — a course of Carlsbad water. He promised to follow my 
instructions ; he did not, however, and, as was to have been 
expected, his symptoms grew rapidly worse. He sold the 
goods under his charge for less than they had cost, made 
presents of whole cases to the wives of purchasers, reported 
sales which had never been made, and behaved otherwise in 
such an unbusiness-like way that his employers were obliged 
to dispense with his services. I then saw him for the second 
time. He was then agitated in manner, incoherent in his 
speech and in his ideas, talked ramblingly about his business, 
and seemed to feel keenly the fact of his dismissal. At the 
same time, if his attention was engaged, he was able to con- 
verse with clearness and precision, and to assume a degree of 
physical and mental composure which left nothing to be de- 
sired. In a few minutes, however, he was off again with his 
long and pointedless discourses about his business, the state 
of the markets, etc. His brother informed me that he had 
many delusions, no one of which was held for more than a 
day or two, and often only for a few minutes. Thus he told 
me in one breath, that he had been summoned to Zurich to 
take charge of a large silk factory in that city, and that he 
had taken passage in a steamer to sail the following day, and 
in the next that he had been requested by the government of 
Japan to start a cotton mill at Yokohama, and that he was 
going to leave that very afternoon for that country ma San 
Francisco. Then he informed me that he was going to open 



CHROMIC INTELLECTUAL MANIA. 357 

a store in New York which was to be different from any other 
in the whole world. Every customer was to receive a present 
of a book by some distinguished author. In this way, he 
said, trade and literature would be encouraged, and the pur- 
chaser would not only be benefited materially, but would at 
the same time have his mind improved. And so he went on, 
forgetting one delusion almost as soon as it was formed, and 
concocting others, to be in their turn forgotten in a few mo- 
ments. 

But with all this there was a sense of the proprieties of 
life, and a general condition of good behavior altogether dif- 
ferent from what we meet with in cases of acute mania. There 
was no such excitement of mind and body, no tendency to 
violence, no tearing of the hair or stripping off of the cloth- 
ing, no shouting or leaping, or indulgence in obscenity or 
profanity, so characteristic of that type of insanity. On the 
contrary, many persons would have failed to see anything in 
his conduct indicative of mental derangement ; and one phy- 
sician whom he consulted told him he was as sane a man as 
there was in the city of New York, and that all he wanted was 
Turkish baths and salt-water injections. I could not per- 
suade his brother that it was necessary to place him in such a 
place as that of Dr. Parsons, at Sing Sing. He proposed to 
keep him in the city, but finally he decided to take him home 
to England. He was in an asylum there for a couple of years, 
and then, as he was much improved, he was brought back to 
this country. On his return, I found that, though mentally 
and physically better, there was still a tendency to wildness 
in conversation, an inaptitude for intellectual exertion, and 
an inability to sleep. By my advice he crossed the plains to 
California, stopping at various places on the way, and on his 
return, several months afterward, he was in almost a normal 
condition. To a skilful observer, however, it is quite evident 
that there is still a proclivity to the formation of delusions, 
though he is able to correct the tendency. As he says, it 
would not take much to throw him on the other side of the 
line. 

L. B., a woman, aged forty-three, entered the BlackwelTs 
Island Lunatic Asylum with the diagnosis of chronic mania. 
On her admission she talked a great deal, but connectedly, 
and had no very evident delusions, but a good many erroneous 
beliefs scarcely distinguishable from them. Thus, she thought 



358 DESCRIPTION AND TREATMENT OF INSANITY. 

her landlord had had her committed to the asylum because 
she could not pay her rent. In her manner she was excited, 
but not violent, and gave no trouble. For several days she 
continued in a pleasant frame of mind, talking almost con- 
tinuously but coherently, and behaving herself well ; but 
about ten days subsequently she became depressed in spirits, 
and wanted a priest sent for. Then she became noisy and 
abusive, talked in a loud voice, and had various delusions, 
among them one that the attendants had stolen her children. 
A year subsequently she was still in the asylum, at times 
having well-marked delusions, and at others apparently free 
from them. During the subsequent four years she had al- 
ternations of excitement and depression, without there being 
any marked change in her condition. The last entry in the 
case-book is dated February 13, 1875 : " Fell on the ice yes- 
terday and bruised her hand and knee ; mental condition un- 
improved, physical health good." * 

J. M., a woman, thirty-five years old, was brought to me 
by her husband, December 18, 1882, to be treated for insanity. 
She had first become affected three years previously, and had 
passed two years in a lunatic asylum without any improve- 
ment having been effected. Her husband, a remarkably in- 
telligent man, had, from the very beginning, kept full notes 
of her case, and, as he put them at my disposal, I have used 
them in the preparation of this synopsis : 

During the autumn of 1879 a series of excitements and 
misfortunes of a family nature occurred, which resulted in 
disturbing her mind to such an extent that a physician was 
consulted. It should be stated that her mother and a ma- 
ternal aunt were insane, the latter dying in an asylum. The 
physician did not recognize any form of mental aberration as 
being present, although she had for some time suffered from 
hallucinations and illusions, and delusions that her family 
did not treat her with sufficient kindness and consideration. 
Things went on without much change, though she was gradu- 
ally getting worse, till in March, 1880, it became necessary 
to send her to an asylum. At this time she had well-marked 
delusions of persecution, and even conceived that her little 
daughter, a child scarcely six years old, had tried to poison 
her. While in the asylum she had two ribs broken, as she 

1 From Dr. Parsons's MS. " Reports of Cases in the New York City Lu- 
natic Asylum, Blackwell's Island." 



CHRONIC INTELLECTUAL MANIA. 359 

declared, by one of the physicians striking her, but, as inves- 
tigation showed, by her falling over a chair while walking 
about the ward in the night. During her entire stay in the 
asylum she continued to hold the delusion that her daugh- 
ter had tried to poison her. Then her husband concluded to 
remove her, and, as she was quiet and able to conduct her- 
self outside of her delusion with reasonable decorum, he was 
hopeful that at home she would be more favorably situated 
than in the asylum for receiving the care which her con- 
dition still required. In a few days after her return, amend- 
ment began, and in a week or two she was, so far as her 
husband could determine, free from any evidence of mental 
aberration. There were no delusions of any kind, and the 
fixed one in regard to her daughter was only remembered as 
a subject for astonishment that she could ever seriously have 
entertained such an idea. 

But in a very short time, her husband states in less than a 
week, she began to be wakeful at night, and to be tormented 
by horrible dreams. Twice he found her walking about the 
house with a lighted candle after everybody else was in bed, 
and she stated, on the first occasion, that she was looking for 
John the Baptist, and on the second that a celebrated 
preacher, whom she named, had got into the dining-room and 
was hid under the table. 

Then she imagined that she was pregnant, and that another 
preacher, whose name she refused to give, but whom she des- 
ignated as her " spiritual essence," had seduced her. This 
was followed the next day by another to the effect that dur- 
ing the night she had been delivered of a child, which had 
been murdered by her husband. All these things she spoke 
of with the utmost sang froid, and conversed with her hus- 
band about them without evincing any of the emotional dis- 
turbances which would doubtless have been exhibited if her er- 
roneous beliefs had become firmly and indubitably established 
in her mind. It was quite evident that, though she accepted 
her delusions to such an extent as to express her belief in 
them, she yet did not absolutely credit them as facts admit- 
ting of no doubt. Indeed, she spoke of them with the man- 
ner of a person relating unpleasant dreams, which, though 
they had made an impression on the mind, were nevertheless 
known to be mere figments of the imagination. The subject 
of intellectual monomania, of either the exalted or depressant 



360 DESCRIPTION AND TREATMENT OF INSANITY. 

type, does not question the truth of his delusions. Argu- 
ments are of no avail with him, and he acts exactly as he 
would act were his false beliefs real convictions. 

Every day, sometimes every hour, there was a new delu- 
sion, and each was almost invariably of such a character as to 
be entirely beyond the limit of possibility. Thus, at one 
time she thought she had been adopted by the Shah of Per- 
sia as his daughter, because, as she said, she was begotten by 
the sun, and the Shah worshipped the sun as his god. At an- 
other she imagined that her husband had become Pope, and 
that, in order to assume the duties of the papacy, it was neces- 
sary for him to be divorced from her. She therefore went 
about the house with a letter to the Governor, in which she 
asked that a divorce might be granted, and which she re- 
quested every one to sign. At times she was much depressed 
in spirits, and wished that she might die, but she never even 
hinted at suicide, and it was quite evident that her wish had 
no very great sincerity in it. Again she was all smiles and 
good nature ; no one was ever so happy as she, and she would 
not change places with the richest or most powerful person 
who ever lived. Even in her moments of deepest mental de- 
pression, as well as in those of greatest exaltation, she talked 
incessantly. But with all this she was entirely capable of 
accurate reasoning upon common every-day topics. She went 
to church, listened attentively to the services and sermons, 
and talked rationally upon the discourses she had heard. 
She attended to all her household duties as well as she ever 
had, going to market every day and purchasing with discrimi- 
nation what was needed. On one occasion, however, she went 
shopping, and came home with forty yards of red and white 
ribbon, which she said she had bought to use for a flag she 
was going to make as a present to an eminent statesman she 
named. When I saw her for the first time she said that she 
had only come to please her husband, and that there was 
nothing the matter with her. She admitted, however, that 
she did not sleep well, and that she suffered from occasional 
pains in the head, and from almost constant dyspepsia. As 
to her mind, she expressed the conviction that it was as good 
as it had ever been, in fact, better, for that it had undergone 
great development in the direction of causality. She was en- 
gaged now, she said, in endeavoring to ascertain the causes 
of all the events that had ever taken place in the world. On 



CHRONIC INTELLECTUAL MANIA. 361 

my asking her if she really believed this, she said she did, 
that she was sure of it, for that several phrenologists had told 
her so, and that, moreover, she had read allusions which she 
was convinced were to her in Dr. Combes' s Phrenological 
Magazine. But, a half hour afterward, on my repeating the 
question, she admitted that she did not believe it, that she 
had been mistaken, and that she was a poor ignorant woman 
who ought to be sent to school in order that she might be 
taught the rudiments of the English language. During her 
visit, which lasted about an hour, she enunciated six distinct 
delusions, not one of which she believed when she took her 
departure. If left to herself, she went on talking, her conver- 
sation consisting entirely of revelations of the various delu- 
sions which passed through her mind. At times she was in- 
coherent both in words and ideas. It was always possible, 
however, by asking her questions, to get her away from her 
erroneous beliefs, and then she spoke coherently and ration- 
ally. Unless her mind was thus engaged, she immediately 
reverted to her own reflections, and became as loquacious as 
before. "While talking about her delusions there was a good 
deal of muscular action ; she gesticulated with animation, 
and alternately laughed and shed tears, in accordance with 
the character of the ideas evolved. But, in the very midst of 
her discourse, a question relating to any very different topic 
which might be addressed to her was sufficient to stop her 
volubility, to sober her, as it were, and to obtain a coherent 
and rational answer. 

I regarded the case as one of chronic intellectual mania, 
secondary to the intellectual monomania with depression with 
which she had previously been affected, and different from 
the latter in its manifestations except in so far as both were 
mainly concerned with the intellect. 

I saw her once subsequently, but her condition was essen- 
tially unchanged. 

Chronic intellectual mania, whether a primary or secondary 
disorder, is of long duration. There is always a tendency to 
the passage into a still lower form of mental derangement — 
dementia— and this is, after two or three years, the usual ter- 
mination. 



302 DESCRIPTION AND TREATMENT OF INSANITY. 



d — REASONING MANIA. 

Although it is scarcely possible that so well marked a 
mental disorder as that which forms the subject of the pres- 
ent consideration could have escaped the notice of the earlier 
observers, no distinct account of it appeared till Pinel, 1 in 
1801, published the first edition of his remarkable work. 
Under the head of "Mania without Delirium," he gave excel- 
lent accounts of several cases, and then in a few words 
summed up his description of the affection : 

"It may," he says, "be continuous, or characterized by 
the occurrence of periodical accessions. There is no marked 
change in the functions of the understanding, the judgment, 
the imagination, the memory, etc., but perversion of the emo- 
tional faculties, and blind impulsions to the perpetration of 
acts of violence, or even of sanguinary fury, without its being 
possible to recognize the existence of any dominant idea, or 
any illusion of the imagination, to which the acts in question 
can be ascribed." 

In the second edition, published in 1809, he treats more 
fully of the subject : 

"We know that one of the varieties of insanity, called in 
the asylums reasoning mania, is especially characterized by 
the most marked coherence of ideas and correctness of judg- 
ment. The lunatic reads, writes, and reflects as though he en- 
joyed his normal reason, and yet he is liable at any time to 
perpetrate some act of violence." 

Farther on, he says, speaking of these cases : 

" The lunatic makes the most correct answers to the ques- 
tions addressed to him, without the least incoherence of ideas 
being noticed." He gives the following instance : 

"A badly directed or neglected education, or rather a 
perverse and undisciplined nature, produces the first symp- 
toms of this species of mental alienation. An only son of 
a weak and yielding mother was indulged in every whim and 
caprice which an irritable and ungovernable temper could 
suggest. The violence of his disposition increased with his 
years, and the unlimited amount of money with which he was 
supplied removed all obstacles to the gratification of his de- 
sires. If resisted, he became furiously angry, and attacked 
his adversary with ferocity. He was, therefore, continually 
1 " Traits medico philosophique sur Validation mentales," Paris, t. ix, p. 155. 



SEASONING MANIA. 363 

embroiled in disputes and quarrels. If a sheep, a dog, a 
horse, or any other animal offended him, he immediately 
killed it. If he went to any public meeting, he was certain 
to come away bruised and bleeding from the blows he had 
received in the brawls he had excited. On the other hand, 
when he arrived at manhood he came into the possession of a 
large property, which he managed with discretion, perform- 
ing all his duties to society, and even indulging in some acts 
of benevolence. Wounds, lawsuits, and heavy fines were gen- 
erally the consequence of his numerous disputes. Finally 
an act of especial violence put an end to his career. Enraged 
at a woman who had used abusive language to him, he seized 
her and threw her into a well. He was arrested and tried, 
and, on the testimony of many persons acquainted with his 
character and furious deportment, he was adjudged insane, 
and was committed to the Bicetre for life." 

Yet, although Pinel had some idea of the affection under 
notice, he did not have a very exact conception of it. He 
seemed to be under the impression that a blind tendency to 
the perpetration of unwarrantable acts of violence is its most 
marked feature, whereas we know very well that such are 
often done by its subjects after very thorough deliberation, 
and from what are deemed ample motives. He certainly had 
in his mind cases in which reasoning mania was combined 
with some form of instinctive or emotional insanity, as the 
instance just cited plainly shows. 

Esquirol, 1 under the designation of " Reasoning Mono- 
mania," describes the disorder more accurately. He says : 

"In reasoning monomania the patients are active, con- 
tinually in motion, speaking a good deal, and with vivacity. 
They were good-tempered, frank, and generous, they have 
become peevish, deceitful, and wicked ; they were affection- 
ate and kind to their relations and friends, they have become 
discontented and abusive to those they once loved ; from 
having been economical they are changed to spendthrifts ; 
their actions were reasonable and right, they are now incon- 
siderate, venturesome, and even reprehensible ; their con- 
duct, which once was in accordance with their social position, 
has become incongruous, and at variance with their position 
and their means. They are guided entirely by their own 
wishes ; but, by their bearing and their conversation, these 

1 "Des maladies mentales," etc., Paris, 1838, t. i, p. 355. 



3G4 DESCRIPTION AND TREATMENT OF INSANITY. 

people impose upon those who have had no previous acquaint- 
ance with them, or who only see them occasionally, so well do 
they know how to restrain themselves, and to dissimulate 
their real feelings." 

The younger Pinel ■ had a still clearer, though yet not an ex- 
act, idea of reasoning mania. "The subjects of it," he says, 
"are turbulent, indocile, quick to anger, committing outrage- 
ous acts, which they are always ready to justify by plausible 
reasons, and who are to their families, their kindred, and 
their friends, constant subjects of anxiety and grief. They 
are continually doing wrong, either by neglect, by malice, or 
by wickedness. Incapable of mental or physical application, 
they destroy and subvert, and unsettle everything with 
which they are brought into contact, and which they can 
injure." 

Pinel calls the affection "Mania of Character," although 
he appears not to regard it as insanity properly so called. In 
this opinion he is very evidently inconsistent with himself. 

Speaking of the subjects of the disorder in question, Mo- 
rel a says : 

"Some have great ambition and pride, and consider them- 
selves as being destined to the performance of acts of mo- 
mentous importance. No consequence, however absurd, to 
which their insanity leads them, shakes their confidence in 
themselves. Others are impelled by bad tendencies to the 
perpetration of the most extravagant or monstrous acts. 
They rebel against all family and social obligations and duties, 
and are constantly considering themselves the victims of mis- 
understanding or injustice. For the persecution of which 
they imagine themselves the subjects they seek to avenge 
themselves on their relations, their friends, and the world at 
large, by making a parade of their immoral conduct, think- 
ing to compromise the interests of those who ought to be dear 
to them by the shameful exhibition of their depravity. They 
go into the streets and other public places in a filthy and 
ragged condition. They let their hair grow, and endeavor to 
attract attention by all kinds of ridiculous and improper acts. 
Others apply their brilliant intellectual faculties, notwith- 
standing they are marked by an irregularity and incoherence 
of action, to the production of literary works of which the ex- 

lu Traite depathologie cer6brale," Paris, 1844, p. 330. 
2 " Traite des maladies mentales," Paris, 1860, p. 546. 



SEASONING MANIA. 365 

tent and the plan exceed the limit that it is possible for 
human power to reach. These works are often in their teach- 
ings contrary to pnblic morality and feeling, They are 
dreamers, Utopians, false guides, who, in their mental con- 
ceptions and in the results of their intelligence and imagina- 
tion, exhibit the same eccentricity, the same shamelessness, as 
in their acts." 

This, it appears to me, is a very exact description of the 
subjects of reasoning mania so far as it goes. There are sev- 
eral phases of the affection, however, upon which Morel has 
not touched. 

Dagonet x less accurately says of them, under the head of 
" Reasoning Mania" : 

"Left to themselves, they are led by the most contradic- 
tory considerations. The first sudden impression, an idea 
occurring by chance, an accidental circumstance, influences 
them, and becomes the point of departure for their conduct. 
There is with them not only a considerable amount of irrita- 
bility, and, thus to say, a furnace ready to be kindled, but, 
in addition, they are habitually dominated by impulses of 
various kinds. They follow blindly the passionate instincts 
which trivial circumstances are constantly provoking. Sex- 
ual desires, jealousy, ambition, vengeance, influence them at 
every moment of their lives, and, notwithstanding their 
wishes, prompt them to the commission of acts to be subse- 
quently regretted. With the best intentions, the individual 
cannot subdue himself, or stop his headlong descent along 
the fatal declivity which leads to disorder. 

"In the institutions to which they may be committed, 
they incite the patients against each other, and urge them to 
acts of insubordination. They take pleasure in worrying the 
attendants with their complaints, and never cease their ani- 
madversions on the directions or advice given them. The most 
various sentiments — suspicion, malevolence, and calumny — 
are the elements in which they live, and without which they 
could not exist." 

I have quoted thus extensively from other authorities in 
order to present at the beginning some idea of the charac- 
teristics of reasoning mania, as well as to show that such a 
mental disorder is well recognized by medico-psychological 

1 " Nouveau traite elementaire et pratique des maladies mentales," Paris, 1876, 
p. 202. 



366 DESCRIPTION AND TREATMENT OF INSANITY. 

writers. I have confined my citations to French authors, for 
the reason that the affection was first differentiated by alien- 
ists of that country, and has been more thoroughly studied 
there than elsewhere, but I might have drawn fully as largely 
from English and German writers. Indeed, Prichard, Connolly, 
Bucknill, and Maudsley among the former, and Hoffbauer, 
Caspar, Griesinger, Liman, Kraft-Ebing, and others of the lat- 
ter, have written quite as strongly in support of the actuality 
of the affection as those I have cited. In this country the most 
distinguished authority in the affirmative is Dr. Isaac Ray. 

The most prominent characteristic of reasoning mania as 
it has come under my notice is an overbearing egotism, which 
shows itself on all, even the most unimportant, occasions. The 
individual is vain of his personal appearance ; he imagines that 
he is the subject of conversation of all whom he sees talking 
together, and that every one who glances toward him carries 
admiration on his countenance. Without social position, with- 
out wealth, without education, and without political influence, 
he conceives that he has only to make his wishes known to 
those in authority to have them granted. He hence does not 
hesitate to push himself forward as an applicant for a high 
office, and this when he has not a single qualification fitting 
him for the position he seeks ; refusals do not dismay him, 
the most pointed rebuffs do not abash him. He is sure that 
his application will be favorably considered, and any little act 
of common politeness that may be shown him is at once con- 
strued into a promise of assistance. He is invariably sure 
his appointment is about to be made, and when, as always 
happens, some other person is selected, his chagrin is of short 
duration. He has some plausible excuse for his failure, and 
at once proceeds to direct his energies toward obtaining 
another and perhaps still higher position. 

It may be said that these are the characteristics of all 
office-seekers, who are generally gifted with vanity in excess 
of all other qualities, but this I emphatically deny. We 
have in this country ample opportunity to study the natural 
history of the class in question, constituting, as they do, a 
large proportion of the inhabitants of the land, and I think 
most observers will bear me out in the assertion that it is ex- 
ceedingly rare to find a person applying for an office for 
which he is totally unfit, and for which he could not obtain 
the endorsement of any intelligent person. 



REASONING MANIA. 367 

Not long since, a young man was under my professional 
charge, who for several years had been the cause of great 
anxiety to his friends on account of his vagaries and general 
impracticability. His father had a large shoe factory, and 
the attempt was made to instruct him in the details of the 
business. It was found, however, impossible to make him 
give his attention to the subject. He was firmly convinced 
that nature intended him for something a great deal better 
than a shoemaker, and he destroyed a good deal of valuable 
property — leather, tools, etc. — in order to disgust his father, 
and induce him to abandon the project. Finally he suc- 
ceeded. 

He had received a tolerably good education in the branches 
usually taught in the public schools, and was, moreover, ex- 
ceedingly quick in his perceptions of things which he desired 
to understand. As he told me the story of what he consid- 
ered to be the wrong done him by his father in trying to 
make a shoemaker of him, he reasoned with great plausibil- 
ity, and tears came into his eyes as he detailed the story of 
the indignity which had been attempted to be put upon him. 
"The fact is," said he, "that when I went to school I paid 
great attention to the study of languages. Now, if I had 
known I was going to be a shoemaker, I would have turned 
my attention to the human foot, and then I should have been 
qualified to make the best shoes this country has ever seen. 
I have thought over the matter, and to-morrow I am going to 
Washington to ask the President to appoint me a Commis- 
sioner of Emigration, and send me to all the nations of Eu- 
rope to see after the emigrants and instruct them in their du- 
ties as American citizens. I shall give lectures on the subject 
in all the principal cities of Great Britain, France, and Ger- 
many." 

"But," said I, "do you speak French ? " 

"Well, I studied French. I can't say I speak it, but I can 
learn it on the way over." 

"You understand German % " 

"No, but as soon as I am in Germany I shall go to a pri- 
vate family to board, and I will soon pick up that language." 

"Do you know anything of political economy % " 

"That is not essential ; emigrants do not require a knowl- 
edge of that science." 

"Now, won't you tell me your idea of the duties of an 



3C8 DESCRIPTION AND TREATMENT OF INSANITY. 

American citizen, in which you are going to instruct these 
people ? " 

"I shall simply read to them the Constitution of the United 
States in their own language, and then distribute copies of 
it among them. That paper," he continued, "contains the 
germs of all that a citizen requires to know." 

"But," I remarked, " there is not a word in the Constitu- 
tion about the duties of citizens. It relates to quite different 
matters." 

" Nothing about the duties of citizens in the Constitution ! 
Well, then, I'll supply the omission ; I'll make it all right ; I 
know just what I'm about, and I'm just the man for the 
place." 

He drew up his application, went around among promi- 
nent persons asking for letters of recommendation, and, 
though he did not get a single one, he proceeded to Washing- 
ton and sought an interview with the President. His father, 
however, followed him, but could not bring him home with- 
out the assistance of the police. He was soon afterward an 
applicant for the command of an ocean steamship, but, meet- 
ing with no success in this direction, turned his attention to 
hunting up claims against the United States, out of which he 
expects to make a great fortune. He asserts that he has as- 
certained that, during the late war with Great Britain, a vast 
amount of property was taken for public use for which no com- 
pensation has ever been made. He declares that he has found 
one heir to whom the Government owes over two millions of 
dollars, and that he is to have half for getting it. He actually 
has such a person under his control — one whom he has doubt- 
less impressed with his own ideas to such an extent as to 
make him believe himself to be justly entitled to the sum 
mentioned. For he is crafty, specious, and insinuating, and 
could readily make a weak-minded person his dupe. 

The intense egotism of these people makes them utterly 
regardless of the feelings and rights of others. Everybody 
and everything must give way to them. Their comfort and 
convenience are to be secured though every one else is made 
unhappy, and sometimes they display positive cruelty in 
their treatment of persons who come in contact with them. 
This tendency is especially seen in their relations with the 
lower animals and with children. 

Another manifestation of their intense personality is their 



EEASOMNG MAKIA. 369 

entire lack of appreciation of kindness done them, or benefits 
of which they have been the recipients. They look npon 
these as so many rights to which they are jnstly entitled, and 
which in the bestowal are more serviceable to the giver than 
to the receiver. They are hence ungrateful and abusive to 
those who have served them, and insolent, arrogant, and 
shamelessly hardened in their conduct toward them. 

At the same time, if advantages are yet to be gained, they 
are sycophantic to nauseousness in their deportment toward 
those from whom the favors are to come. 

They never evince the least trace of modesty in obtruding 
themselves and their assumed good qualities upon the public 
at every opportunity. They boast of their genius, their right- 
eousness, their goodness of heart, their high sense of honor, 
their learning, and other qualities and acquirements, and this 
when they are perfectly aware that they are commonplace, 
irreligious, cruel, and vindictive, utterly devoid of every chiv- 
alrous feeling, and saturated with ignorance. They know 
that in their ran tings they are attempting to impose upon 
those whom they address, and will often, as I have personally 
experienced, brag of their success in deception. 

It is no uncommon thing for the reasoning maniac, still in- 
fluenced by his supreme egotism and desire for notoriety, to 
attempt the part of the reformer. Generally he selects a prac- 
tice or custom in which there is really no abuse. His energy 
and the logical manner in which he presents his views, based, 
as they often are, on cases and statistics, impose on many 
worthy people, who eagerly adopt him as a genuine over- 
thrower of a vicious or degrading measure. But sensible per- 
sons soon perceive that there is no sincerity in his conduct, 
that he cares nothing whatever for the cause he is advocating, 
that his cases or statistics are forged or intentionally miscon- 
strued for the distinct purpose of deceiving; in short, that 
his philanthropy or morality which he affects is assumed for 
the occasion. Eren when his hypocrisy and falsehood are 
exposed, he continues his attempts at imposition, and even, 
when the strong arm of the law is laid upon him, prates of 
the ingratitude of those he has been endeavoring to assist, 
and of the disinterestedness and purity of his own motives. 

Again, the reasoning maniac, as Campagne ' remarks, may 
go still further in his career as a redresser of all kinds of pos- 

1 " Traite de la manie raisonnante," Paris, 1869, p. 98. 
24 



370 DESCRIPTION AND TREATMENT OF INSANITY. 

sible and impossible wrongs — past, present, and future. " He 
displays in the performance of his part a degree of energy, 
activity, and caution which would be really admirable if his 
mission had any foundation whatever. Unfortunately, his 
warfare is waged against windmills, and. he takes for incon- 
testable truth that which is only a figment of his imagination. 
Truth with him becomes error, from the exaggeration, the de- 
preciation, or the distortion to which it is submitted. He 
regards virtue through the medium of his own degraded pas- 
sions, and never as it ought to be seen. Thus estimated, it 
cannot direct him to any good purpose." 

The subject of reasoning mania is always more influenced 
by the emotions than by the intellect ; not, however, because 
these latter have become stronger or more active, but because, 
his intellect being deranged either qualitatively or quanti- 
tatively, he does not subject them to proper control. In fact, 
he rarely judges calmly or dispassionately on any matter 
brought before him. The slightest cause often produces in 
him an intense degree of excitement, and he manifests his 
emotional disturbance by loud exclamations, vehement ges- 
tures, and the most foul and abusive language against those 
who have incurred his resentment. But, even when apparently 
most inflamed, and in the very midst of his maledictions, he 
becomes, under the influence of some different circumstances, 
good-natured and smiling, and finishes his cursing with a joke 
or a hearty laugh. There is no depth or sincerity either in 
his imprecations or his blessings. 

This facility for passing from one state of feeling to 
another, both of which may be manifested by all the character- 
istics of intense passionate perturbation, is a striking pecu- 
liarity of reasoning maniacs. Of all people in the world, 
they seem to be the most capable of " blowing hot and cold 
with the same breath." A patient of mine, a young man, 
would in my presence declaim in the most vehement manner 
against his father, accusing him of all the sins of the deca- 
logue, and of many others not found in that code, and in the 
next instant would declare that he was only trying to test his 
father's patience and forbearance, and that in reality no one 
could be kinder or more virtuous than he. But, ere these lat- 
ter opinions were fully expressed, I caught him making faces 
and shaking his fists at his father when his back was turned. 
It was impossible to get at his real feelings, not, however, be- 



KEASONING MANIA. 371 

cause he wilfully concealed them, but because he expressed, 
with apparently equal sincerity, love and hatred in all their 
degrees. 

All authors have observed this symptom. Campagne ' says, 
of reasoning maniacs : 

" Passing, without the slightest transition, from one ex- 
treme to the other, they felicitate themselves to-day of an 
event which they sneered at the night before. In the course 
of a single second they change their opinions of persons and 
things ; novelty captivates and wearies them almost at the 
same instant. They sell for insignificant sums things they 
have just bought, in order to buy others which in their turn 
will be subjected to like treatment ; and, strange to say, be- 
fore possessing these objects, they covet them with a degree 
of ardor only equalled by the eagerness they exhibit to get 
rid of them as soon as they become their owners. To see, to 
desire, and to become indifferent, are the three stages which 
follow each other with astonishing rapidity." 

Although reasoning maniacs are not subject to irresistible 
impulses to commit motiveless crimes, they are prone to acts 
of violence from slight exciting causes, and these may be per- 
petrated either in the heat of passion or after such deliber- 
ation as they are able to give to any subject. Generally they 
are directed against those whom they suppose have injured 
them, or against former friends with whom they have quar- 
relled. Again, they may be committed solely for the pur- 
pose of gratifying the morbid feelings of pleasure which they 
experience at the sufferings of others. In the first category 
are embraced the many cases of arson, maiming, homicide, 
and other crimes, in which the motive alleged has been so 
slight as to be ridiculous. 

Thus, in the case of William Speirs, 3 who attempted to 
destroy by fire the State Lunatic Asylum at Utica, there was 
a motive, though a very insufficient one, for the act. On the 
14th of July, 1857, the cupola of the institution was dis- 
covered to be on fire. The central building was almost en- 
tirely consumed before the flames were subdued. Four days 
afterward, in the afternoon, the store, barn, and stables were 
also seen in flames, and a man was noticed at the time going 
from them. This man was William Speirs, who had been a 
patient in the asylum from 1850 to 1856, and then, having been 

1 Op. tit., p. 88. 2 American Journal of Insanity, vol. xv, 1858-'o9, p. 200. 



372 DESCRIPTION AND TREATMENT OF INSANITY. 

discharged by an order of a Justice of the Supreme Court, 
had been employed up to the time of the fire as a messenger 
and otherwise. He had been committed to the asylum on the 
ground of insanity, after a trial for arson, so that he had per- 
petrated at least three separate acts of incendiarism. He con- 
fessed to both the attempts at Utica, and was committed for 
trial on the charge of arson. 

At the trial it was shown by his own confession how and 
for what reason he had set fire to the asylum. His motives 
were the facts that one of the assistants, Dr. Chapin, had sent 
him away from where they were making balloons, and would 
not let him help, and that Dr. Gray, the superintendent, had 
taken away his keys. These acts made him angry. 

It was also shown that Speirs had previously been a pa- 
tient in the lunatic asylum on Blackwell's Island ; that he had 
had a sunstroke ; that after that he would go out and stay 
whole days and nights, on one occasion remaining absent 
from home eight days, sleeping in wagons. During this 
period he went into a house and got some things, and was 
going to set it on fire, when he was discovered. He was tried 
and sent to the Blackwell's Island Asylum. Then he came 
to the city and got some work in a saloon. "Did some dep- 
redations there," was tried, and sent to the asylum at Utica. 
A sister was also insane, and had been in an asylum. Drs. 
Day and Deming, of Utica, and Dr. H. M. Ranney, the superin- 
tendent of the Blackwell's Island Asylum, testified to the in- 
sanity of the prisoner. The latter, under whose care Speirs 
had been, was very positive as to his insanity. 

"I discovered no delusion," he said ; " think he has no 
uncontrollable impulse. 1 believe the act resulted from a 
perverted condition of the several moral faculties of the mind, 
with a propensity to burn buildings, and a feeble intellect. 
. . . Perhaps anything that would excite the prisoner would 
induce him to burn buildings, or even might stimulate him to 
commit an assault with intent to kill. I judge that he is a 
pyromaniac, because he has committed these acts and is in- 
sane." 

Drs. Gray, Cook, and Bell, however, testified to the sanity 
of the prisoner. The former stated that he had never be- 
lieved him to be insane. We have seen, however, that he was 
kept in the asylum, under the charge of lunacy, for six years. 
Speirs was convicted. 



REASONING MANIA. 373 

Joseph Brown, as stated by Dr. Harlow, 1 entered his own 
house on the morning of the 16th of April, 1856, shortly after 
breakfast, where his wife, Annie Brown, was engaged with 
her domestic duties. Their little daughter, aged, twelve, was 
also present. Brown went to his daughter, and taking out 
his wallet containing twenty dollars, gave it to her. On turn- 
ing toward his wife, she kindly said to him, " Joseph, I am 
afraid of you." On which he immediately seized a long 
sheath-knife with one hand, and with the other threw her 
upon the floor ; while in this position he cut her throat, sever- 
ing the jugular vein, from which she died. 

It is stated that Brown was at this time about forty years 
of age, a member of the church, taking a prominent part in 
the religious exercises, and speaking loudly and vehemently. 
It was noticed, however, that his outside conduct did not 
comport well with his teaching. He indulged more or less in 
the use of stimulants. He was irritable and quarrelsome. 
His bad temper was particularly exhibited toward his wife, 
who was a feeble woman. He had been known to strike her 
with his fist, and to kick her from a chair, and this though 
there had been no provocation. Subsequently, he again, with- 
out a cause, kicked her from the chair on which she was sit- 
ting, and struck her violently on the head with a pair of 
boots. On this occasion he left the house, but soon returned, 
and gave his little daughter a piece of money. He was not 
intoxicated, and there had been no exciting conversation. 
After this he frequently threatened his wife with assault, and 
she was obliged to flee from the house to escape him. 

Immediately before the murder he had had a quarrel with 
his brother, and tried to choke him. On being prevented, 
he laughed heartily, and left the house. Shortly afterward 
he returned, and, breaking open the door, threatened the 
whole family with violence. After sufficiently alarming them, 
he ran away rapidly for several hundred feet. 

He accused his wife of infidelity, but exhibited no indig- 
nation or excitement at the idea. 

The day before the murder he went to Belfast, but before 
going placed the following inscription on paper upon the 
door of his house : ' ' Farewell, house, wife, and blessed little 
children ! " At Belfast he drank, as he said, a quart of gin. 
On Wednesday morning at two o'clock he left for home, and 

1 American Journal of Insanity, vol. xiii, 1856-'57, p. 249. 



374 DESCRIPTION AND TREATMENT OF INSANITY. 

arrived there at about seven o'clock. Shortly afterward he 
committed the murder. 

He then, after making two futile attempts to drown him- 
self, was secured and lodged in prison. 

Brown's grandfather was subject to fits of depression, and 
once nearly succeeded in cutting his throat. His grand- 
mother lived to be over seventy, and during the latter period 
of her life was demented and under the care of legal guar- 
dians. His mother was passionate and excitable, and her 
peculiarities were the subject of remark by the neighbors. 
An uncle was found drowned, and was supposed to have 
committed suicide. A brother had an attack of fever which 
was followed by mental aberration. 

At the trial, Dr. H. M. Harlow, superintendent of the in- 
sane asylum at Augusta, testified strongly in favor of the 
prisoner's insanity. He was, however, found guilty, and was 
sentenced to be hanged. Before the sentence could be exe- 
cuted he committed suicide by cutting his throat with a piece 
of glass, thus adding, as Dr. Harlow says, the capstone to the 
accumulated evidence of his insanity and irresponsibility. 

Helene Jegado, a Frenchwoman, between the years 1853 
and 1857, killed twenty- eight persons by poison, besides mak- 
ing several unsuccessful attempts. In none of her murders 
was any cause alleged or discovered, though undoubtedly the 
pleasure derived from the perpetration of crime was the chief 
factor. Her victims were her masters and mistresses, her 
fellow-servants, her friends, and several nuns, for whom in 
their last moments she displayed the utmost tenderness and 
care. The plea of monomania was set up in her defence, but 
no evidence of insanity was brought forward by her counsel 
save the apparent want of motive for her crimes. It was 
shown, however, that she had begun her career, when only 
seventeen years old, by attempting to poison her confessor ; 
that she had, while perpetrating her wholesale murders, af- 
fected the greatest piety, and was for a time an inmate of a 
convent ; that she had committed over thirty thefts ; that she 
had maliciously cut and burned various articles of clothing 
placed in her charge ; that, when asked why she had stolen 
things that were of no use to her, she had replied, " I always 
steal when I am angry" ; that she was subject to alternate 
periods of great mental depression and excessive and unrea- 
sonable gayety ; that she was affected with pains in the head 



SEASONING MANIA. 375 

and vertigo ; that when she was angry she vomited blood ; 
and that, while in prison awaiting trial, she was constantly 
laughing and joking about indifferent subjects. She was 
found guilty, and, on being asked if she had anything to say 
why sentence of death should not be pronounced, made an- 
swer, "No, your Honor, I am innocent* I am resigned to all 
that may happen. I would rather die innocent than live 
guilty. You have judged me, but God will judge you." 
Her last words on the scaffold were directed to accusing a 
woman as her instigator and accomplice, whose name was not 
even mentioned during the trial, and who, upon inquiry, was 
found to be an old paralytic, whose whole life had been of the 
most exemplary character. 

The case of Dumollard is in some respects similar to that 
of Helene Jegado. This man, a peasant, of a low order of in- 
tellect, but by no means an imbecile, was plunged in the low- 
est depths of ignorance and want. The moral sense appeared 
never to have been developed in him ; he was a savage, pure 
and simple ; he was out of place among civilized people. 
This monster had a penchant for murdering servant-girls 
whom he pretended to hire, and then, conducting them to un- 
frequented places, put them to death. Six thus disappeared, 
and nine others barely escaped. Indeed, it is probable that 
many more than these were murdered, for, on searching his 
premises, twelve hundred and fifty articles of women's ap- 
parel were found, of which only fifty were identified. In- 
sanity was urged in his defence, but he was found guilty and 
executed. On the scaffold he behaved with the utmost in- 
sensibility. His last words were addressed to an officer, and 
were a request to tell his wife that a man, Berthet by name, 
owed him twenty-seven francs less a sou. 

The most noted case of similar character occurring in this 
country is that of Jesse Pomeroy, the boy torturer and mur- 
derer of Massachusetts. In 1872 there was great excitement in 
Chelsea, near Boston, over a number of horrible instances of 
cruelty perpetrated on little children. The victims were tor- 
tured in various ways — sometimes by being cut with knives 
in various parts of their bodies, again by being tied to beams 
and beaten with ropes and sticks till their bones were broken 
or their teeth knocked out, and again by having pins and 
needles run into sensitive parts of their bodies, upon which 
salt water was afterward poured. Pomeroy, a boy fourteen 



376 DESCRIPTION AND TREATMENT OF INSANITY. 

years of age, and the son of a respectable widow, was ascer- 
tained to be the perpetrator after about a hundred other boys 
had been arrested on suspicion. When arraigned, he admitted 
his guilt, and could only plead in his defence that he " could 
not help it." He was convicted, and sent to the House of 
Refuge. After remaining there a year and five months, he 
was — at the earnest request of his mother, and, furthermore, in 
view of his good conduct while in confinement — pardoned, and 
on the 6th of February, 1874, he returned home. On the 22d of 
April, a little fellow named Horace Mullen, the son of a poor 
cabinet-maker, was found dead in the Dorchester marshes. 
The body was horribly mutilated, the head was nearly sev- 
ered from the trunk, and about thirty stabs were found in 
different parts of the corpse. Jesse Pomeroy was at once sus- 
pected as the murderer. On examination, a knife spotted 
with blood was found on his person, another spot on the 
breast of his shirt, and his boots were covered with mud like 
that found in the marshes. Upon repairing to the place where 
the body had been found, the officers discovered footprints 
which corresponded with those made by Pomeroy's boots. 
When confronted with the body of the murdered child, Pome- 
roy trembled all over, and turned away his head. 

" Did you know that little boy 1 " inquired the officer. 

" Yes, sir, but I don't want to look at him any more." 

" Did you kill him % " 

"I suppose I did." 

" How did you get the blood off the knife ? Did you wash 
it?" 

"No, sir, I stuck it in the mud." 

He was found guilty, and sentenced to be hanged, but his 
punishment was commuted to imprisonment for life. He has 
made several ingenious but unsuccessful attempts to escape, 
and has proven to be altogether intractable. 

These cases are sufficient to illustrate the relations of rea- 
soning mania to crime. They show, also, how slight may be 
the extraneous motive which prompts to the perpetration of 
criminal acts, and how strong is the innate feeling of per- 
sonal gratification, born as it is of intense selfishness, which 
leads in the same direction. Dr. Ray ' has touched the exact 
point when he relates the following incident : 

1 " A Treatise on the Medical Jurisprudence of Insanity," fifth edition, Bos- 
ton, 1871, p. 223. 



REASONING MANIA. 377 

"I once asked a patient, who was constantly saying or 
doing something to annoy or distress others, while his intel- 
lect was apparently as free from delusion or any other im- 
pairment as ever, whether, when committing his aggressive 
acts, he felt constrained by an irresistible impulse contrary to 
his convictions of right, or was not aware at the moment that 
he was doing wrong. His reply should sink deeply into the 
hearts of those who legislate for, or sit in judgment on, the 
insane. ' I never acted from an irresistible impulse nor upon 
the belief that I was doing right. I knew perfectly well I 
was doing wrong, and I might have refrained if I had pleased. 
I did thus and so because I loved to do it ; it gave me an in- 
describable pleasure to do wrong.'" 

As Campagne says : 

"The intellectual power of reasoning maniacs is not great. 
Loquacious or unusually taciturn, heedless or morbidly curi- 
ous dreamers, wearisome to all brought in contact with them, 
capricious and unmitigated liars,, their qualities are often, in a 
certain manner, brilliant, but are entirely without solidity or 
depth. Sharpness and cunning are not often wanting, es- 
pecially for little things and insignificant intrigues ; ever 
armed with a lively imagination and quick comprehension, 
they readily appropriate the ideas of others, developing or 
transforming them, and giving them the stamp of their own 
individuality. But the creative force is not there, and they 
rarely possess enough mental vigor to get their own living." 

As to derangement of the intellect, continual study of the 
subject and the careful examination of some recent striking 
cases convince me that, though the emotions and the will are 
involved, the intellectual faculties are those which chiefly 
suffer. In a superficial examination, the intellect may appear 
to be unaffected, as it very generally happens that there is an 
absence of marked delusion. But a morbid susceptibility to 
be impressed by slight exciting causes ; an unquestioning faith 
in their own powers when these are far below the average ; an 
entire disregard of their duties and obligations and of the or- 
dinary proprieties of life ; an impossibility of mental appli- 
cation or concentration for any considerable period ; deficient 
powers of judgment in matters of the utmost simplicity ; a 
general wrong-headedness, which prevents them perceiving 
matters submitted to their understanding as the mass of man- 
kind regard them — are certainly indications of intellectual 



378 DESCRIPTION AND TREATMENT OF INSANITY. 

derangement. Most authors who have described the affection 
appear to think that it invariably exists without the partici- 
pation of the intellect, and I was myself at one time of the 
opinion that this part of the mind was not its chief seat. 
More complete investigation has, however,- shown me that this 
view is wrong, and that it is as regards the intellect that the 
most striking manifestations of reasoning mania are exhib- 
ited. Again, others, perceiving that the intellect participates 
to some extent in all cases of mental derangement, refuse to 
admit the existence of reasoning mania as a distinct patho- 
logical entity. 

Reasoning mania, or at least the proclivity to it, is usually 
a congenital affection, though there are cases in which it has 
been acquired either as the consequence of other diseases, 
or of injuries, or as the result of degenerating physical and 
mental factors. Occasionally it is only developed in either 
sex at the advent of puberty. Again, it is sometimes inter- 
mittent in its manifestations, being particularly liable to ex- 
hibit activity in times of great public excitement. 

According to Campagne, 1 there is no tendency in reasoning 
mania to degenerate into dementia, but there is reason to 
believe that the peculiar mental and bodily conditions which 
exist in reasoning mania may develop into the characteris- 
tic of general paralysis of the insane. The one affection is, 
therefore, probably not infrequently the precursor of the other. 
Thus, Brierre de Boismont a has pointed out that in general 
paralysis of the insane there are sometimes perversions of 
the moral sense, great irritability, failure of memory, and de- 
fects of judgment, preceding by several years the development 
of the special symptoms of the disease. Gruislain 3 also cites 
cases in which mental symptoms similar to those mentioned 
made their appearance several years before any derangement 
of motility was observed, and when there was reason to sus- 
pect that general paralysis of the insane was lurking in the 
background. 

Relative to the bodily peculiarities of reasoning maniacs, 
Campagne 4 says : 

1. That the head is smaller than that of persons of sound 
mind. 

1 Op. cit., p. 200. 2 Annates medico psychologiques, t. vii, 1861, p. 88. 

3 " Lemons orales sur les phrenopathies," Gund, Paris, 1880, t.i, p. 266, et seq. 

4 Op. cit., p. 146. 



REASONING MANIA. 379 

2. That it is smaller than that of lunatics in general. 

3. That, as regards size, it is almost equal to that of per- 
sons of weak minds. 

4. That it is larger than that of idiots. 

5. That the antero-posterior curve, and particularly the 
posterior curve of the cranium, are less than those of persons 
of sound mind, lunatics in general, the weak-minded, and 
even idiots. It may be said that reasoning maniacs have a 
congenital atrophy of the posterior lobes of the brain, and 
that the cranium has been diminished in size at the expense 
of the occipital region. 

This would conclude what I have to say relative to rea- 
soning mania but for the recent existence of a marked ex- 
ample of the affection in the person of Charles J. Guiteau, 
the assassin of President Garfield. On the hypothetical ques- 
tion proposed by the prosecution, it is sufficiently apparent 
that the prisoner was of unsound mind ; and that his men- 
tal aberration is properly to be regarded as reasoning mania 
is, I think, equally clear. That question contains the follow- 
ing statements, accepted by the prosecution as facts : 

That he had several insane relatives ; that while at college 
he abandoned his studies and entered the Oneida Community ; 
that he left it, and subsequently returned ; that he .again left 
it and went to New York to establish a newspaper devoted to 
the dissemination of peculiar religious ideas ; that he aban- 
doned this project ; that he studied law, and was admitted 
to the bar ; that he was married, and then divorced by his own 
procurement ; that he became interested in religion, and de- 
livered lectures on the subject ; that while thus engaged he 
attempted to strike his sister with an axe ; that, though a 
physician could find neither illusion, hallucination, nor de- 
lusion, he pronounced him insane "because of exaltation of 
the motives and expressions of emotional feeling, also exces- 
sive egotism, and that he was the subject of pseudo-religious 
feelings," and advised his confinement in a lunatic asylum ; 
that he soon afterward gave up lecturing ; that he associated 
himself with the National Republican Committee, and pre- 
pared a speech, which, however, he only delivered once ; that 
after the election of General Garfield he asked by letter for 
the appointment of Minister to Austria ; that he went to 
TTashington to urge his claims ; that, not getting the posi- 
tion he applied for — that of Consul at Paris — "he earnestly 



3S0 DESCRIPTION AND TREATMENT OF INSANITY. 

and persistently followed up his application by verbal and 
written requests, having no special claims for this place ex- 
cept his own idea of the value of his services," and having 
the recommendation of but one person ; that he unwarrant- 
ably inferred from a remark of the Secretary of State that he 
might be appointed ; that, in spite of rebuffs from the officials 
in authority, he continued to expect the appointment ; that 
he made inquiries about a pistol which he subsequently pur- 
chased, borrowing money to pay for it ; that he practiced 
with it by shooting at a mark ; that he followed the Presi- 
dent on two occasions for the purpose of killing him, but 
was deterred once because his wife, who was sick, was with 
him ; that finally he lay in wait for him at the railroad sta- 
tion and shot at him twice, intending to kill him, and inflict- 
ing a mortal wound. 

That after the shooting he attempted to get to the jail for 
protection ; that he was arrested, and that a letter to General 
Sherman, asking for troops to protect him, was found upon 
his person ; that, in two letters written several days before the 
shooting, he declares that the President's nomination was an 
act of God, that he has just shot the President, u that his 
election was an act of God, his removal an act of God"; 
that in another document, addressed to the American people, 
and dated as early as June 16th, he used this language : " I 
conceived the idea of removing the President four weeks ago ; 
I conceived the idea myself, and kept it to myself," and other 
words of like character. 

That he subsequently claimed that. he was inspired by the 
Deity to kill the President, and that he had had previous in- 
spirations ; that, for years before the shooting, he had pro- 
cured a precarious living, not paying his board bills, borrow- 
ing money, evading the payment of his railway fares, retain- 
ing money collected by him as a lawyer, and being several 
times in prison on charges of fraud ; and that on the stand 
he stated that he felt remorse for his deed so far as his per- 
sonal feelings were concerned, but that his duty to the Lord 
and the American people was paramount. 

On such a statement of facts as the above, and with a 
knowledge of the manner in which the prisoner conducted 
himself while being tried for his life, his abuse of his friends 
who were endeavoring to save him, his praise of judge and 
jury and opposing counsel at one time, and his fierce denun- 



KEASONING MANIA. 381 

eiation of them at another, his speech in his defence, his en- 
tire lack of appreciation of the circumstances surrounding 
him, his evident misapprehension of the feelings of the people 
toward him, his belief in the intercession of prominent per- 
sons in his behalf, and of his eventual triumph, his conduct in 
court after sentence was pronounced, his behavior on the scaf- 
fold, and, finally, the indubitable evidences of brain disease 
found on post-mortem examination, 1 show that Guiteau was a 
reasoning maniac, and hence a lunatic. There is not an asylum 
under the charge of any one of the medical experts for the 
prosecution, or, in fact, any other large asylum in any part of 
the world, that does not contain patients less insane than he. 

Like some other reasoning maniacs, Guiteau feigned a dif- 
ferent form of insanity from that which he really possessed. 
It is extremely probable that all his talk about feeling him- 
self called by God to " remove the President " was made for 
the purpose of causing the belief to prevail that he was in- 
sane, and that he never really had any delusion of the kind, 
or, in fact, any insane delusions of any kind, other than such 
as were the result of his overweening egotism, selfishness, and 
general impracticability. As Campagne a shows, the subjects 
of reasoning mania are not only capable of concealing their 
own mental aberration when they have a purpose to accom- 
plish, but are also able to feign such symptoms as their ex- 
perience teaches them are generally regarded as being more 
markedly characteristic of insanity than those peculiar to 
their real morbid condition. 

e — INTELLECTUAL SUBJECTIVE MOEBID IMPULSES. 

1. By an intellectual subjective morbid impulse is to be 
understood, first, the occurrence and recurrence of an idea 

1 In addition to the fact that Guiteau's head had the shape peculiar to rea- 
soning maniacs, it was ascertained, on post-mortem examination, that the mem- 
branes of the Drain were in places strongly adherent to the skull, and that the 
arachnoid was studded with opalescent patches. Microscopically, it was found 
that there was " unquestionable evidence of decided chronic disease of the mi- 
nute blood-vessels in numerous minute diffused areas, accompanied by alterations 
of the cellular elements." So far as I am aware, this is the first case of reason- 
ing mania in which the brain has been examined. That the patho-anatomical 
condition was that of incipient general paralysis is admitted by some of .the 
most competent alienists in this and other countries, and is especially interest- 
ing in view of the opinion I have expressed relative to the connection of this 
form of insanity with reasoning mania. a Op. cit., p. 393. 



382 DESCRIPTION AND TREATMENT OF INSANITY. 

which is known to be false, and, therefore, is not a delusion, 
but which by its persistency causes more or less mental de- 
rangement, and the logical consequences of which are re- 
stricted to the individual in whom it exists. 

In a very interesting communication .made by Billod l to 
the Societe medico psycliologique, December, 1869, he de- 
scribes the condition in question, and adduces several cases in 
illustration of his views : 

"I know very well," said one of his patients to him as he 
was going through the asylum wards, " that it is all false, but it 
torments me just as much as though it were true. You know 
my two nieces ; they are excellent girls, with hearts of gold. 
I am sure of them, and of their loving feelings toward me, 
and yet I am continually haunted with the idea that they 
wish to poison me, in order to receive at once the property 
which will come to them at my death. It is absurd ; I know 
its falsity ; I am ashamed of having such thoughts, but I 
cannot prevent them, and they distress me just as much as 
though they were true." 

A lady consulted me who, for several weeks, had been 
subject to intellectual derangement, characterized by the con- 
stant recurrence of the idea that she was followed -by detec- 
tives for the purpose of discovering whether or not she vis- 
ited improper places. She was fully aware of the utter 
groundlessness of the thought ; it was not for a moment ac- 
cepted as being true, and yet it annoyed her beyond expres- 
sion by its very persistency. Do what she would, she could 
not escape from it, and she went to bed every night knowing 
that at the instant of awaking it would be present in her 
mind, and hoping that she might die in her sleep. "I am 
afraid," she said, "that eventually I will really believe it, and 
then I shall be actually insane." She had taken every possible 
means to assure herself of the falsity of the idea, but, although 
everything established this fact, she was still pursued by the 
notion. For days she would stay in her bedroom, and, lock- 
ing the doors, would sit down in the vain attempt to read 
some book which she hoped might divert her thoughts, but 
immediately the idea arose, " He is under the bed ; he came 
in before you locked the doors." At first she would resist, 
but eventually she would have to look under the bed. Then 

1 " Des alienes avec conscience de leur etat," " Des maladies mentales," etc., 
Paris, 1882, t. i, p. 492. 



INTELLECTUAL SUBJECTIVE MORBID IMPULSES. 383 

for a few minutes there would be a little rest, but again it 
would come : " You did not look in the wardrobe ; he is there 
concealed behind your frocks." And again she would be 
obliged to search, and so it went on all day, and day after 
day, till her life was a burden to her, and she seriously con- 
templated suicide. Lately she had not been quite sure that 
there were not hallucinations of hearing. So distinct was 
the idea as it was formed in ideal words that it almost 
seemed to her as though she heard them plainly uttered. 

In another case, that of a young lady, who had overworked 
herself at school in the endeavor to learn the higher mathe- 
matics, the thought constantly recurred that she was de- 
scended from insane ancestors, and that she was, therefore, 
in danger of becoming the subject of mental aberration. She 
knew at the time that there had not been an insane person in 
her family, so far back as records went, and that was two or 
three hundred years, and, therefore, the idea was not accepted 
as true. On the contrary, she took the matter very pleas- 
antly, often laughing over it, and speaking of how she would 
amuse herself if she really should be committed to an asy- 
lum. But all this was mere badinage, as she did not, except 
occasionally for an instant, entertain the slightest fear of such 
a termination. With her the idea resolved itself into words 
which she felt obliged to repeat to herself, and sometimes 
even to utter aloud : 

" My father and mother were both insane, 
And I inherit the dreadful stain ; 
My grandfathers, grandmothers, aunts, and uncles 
Were lunatics all, and had carbuncles." 
Mght and day, while awake, this silly stanza was passing 
through her mind in all the variations of accent, time, and 
arrangement. Sometimes with the emphasis on one word, 
and then on another ; sometimes very fast, and again very 
slow, and with all possible combinations of the words and 
lines. Indeed, it was often a task which occupied several 
hours of the day to arrange the elements of the verse into 
new combinations. 

Lately she had been mentally singing it to all the tunes 
she had ever heard, and this caused her more discomfort than 
any other manifestation, for she had a good musical ear and 
education, and, consequently, suffered from the incongruous 
and unmelodious refrain which was constantly in her mind. 



381 DESCRIPTION AND TREATMENT OF INSANITY. 

But nothing interfered with her good temper, though at times 
she was fearful that, through the persistency of the idea, her 
mind might become weakened. "I know I am not insane," 
she said, " and I hope I shall never become so, and I know 
that all my relations were of sound mind, but I should like 
to get rid of the foolish notion, and the eternal verse. I 
might stand them a year longer, but not longer ; no," she con- 
tinued, gravely, after a slight pause, "I don't think I could 
endure them longer than a year." 

2. Or the tendency may be to the recurrence of an idea, or 
a mental image, which, though true enough, and probably at 
some anterior period entertained with pleasure, now wearies 
with constant reiteration, and may give rise to secondary 
mental and physical disturbance. 

In a previous chapter I have incidentally alluded to a like 
condition, but have now to consider it more specifically. A 
case or two will explain it more clearly than any mere de- 
scription. 

A young man, a salesman in a hardware store, had a good 
deal of additional labor put upon him at the close of the 
year in taking an account of the stock on hand. He reached 
his home every night for a week at not far from midnight, 
and then, after eating a hasty but hearty supper, went to bed. 
But not to sleep. All night long his mind was filled with 
ideas of screws, tacks, locks, shovels, carpenters' tools, etc.; 
and images of these objects, and hundreds of others, were 
passing in a confused medley before him. In addition, there 
was an arrangement of words representing the principal ar- 
ticles kept for sale, which he was obliged to repeat mentally, 
and which, of course, added to his uneasiness. Toward morn- 
ing he fell asleep for an hour or two only, and during the 
day, though exhausted, he was free from his troubles. As 
soon, however, as he got to bed, the same sequence was re- 
sumed with undiminished force, and kept on as before, till 
near morning. 

But in the course of a week the taking of stock was com- 
pleted. Instead, however, of obtaining relief from his ideas 
and mental hallucinations, they were increased tenfold, ap- 
pearing in the day as well as in the night, preventing any- 
thing like a proper degree of attention to his business, and al- 
most driving him to despair. Indeed, on account of the cere- 
bral hyperemia which evidently existed in this case, and 



INTELLECTUAL SUBJECTIVE MORBID IMPULSES. 385 

which was indicated by the pain in the head, vertigo, insom- 
nia, tinnitus aurium, as well as by the mental condition, there 
was every reason for regarding the matter from a serious 
point of view. 

Luys, 1 under the head of Hyperemia of the Specially In- 
tellectual Regions, cites a similar case : 

A young professor of mathematics, whose duty it was 
to prepare pupils for examination at the Polytechnic, was 
obliged, in the course of the day, to repeat his demonstrations 
in a loud tone many times. In a short time the mental 
erethism developed was so intense that, even when out of 
the class-room and endeavoring to get rest, the geometrical 
figures he had been employing all day appeared to his im- 
agination. He heard himself speak, and he was impelled to 
repeat mentally the same words, the same problems, the same 
demonstrations, which he had used in the morning with his 
pupils. If he went out for a walk in the country, the same 
images pursued him. With all this, there were pain in the 
head and persistent insomnia. The symptoms continued for 
several weeks, and then disappeared under rest and appro- 
priate treatment. 

1 have had several cases under my charge in which un- 
meaning or almost meaningless phrases continued to be men- 
tally repeated long after the idea which originally excited 
them had disappeared, if there ever had been any such ori- 
gin. Thus, one gentleman had the words " Can't get over 
the fence in time ? ' constantly occurring to him. This phrase 
had its origin in a vivid dream, in which the patient im- 
agined himself pursued by a wild bull, and in which, to save 
himself, he had run toward a high fence. In the morning the 
impression was so strong that he found himself repeating 
the words which expressed the fear he had experienced in his 
sleep, and, for several weeks previous to my seeing him, they 
had been running through his mind in all kinds of ways — 
sometimes to mental music, and then in several languages 
with which he was acquainted. 

But the first account of intellectual subjective morbid im- 
pulses was given by the author 2 in a monograph " On Sleep 

1 " Traits clinique et pratique des maladies mentales," Paris, 1881, p. 433. 

2 New York Medical Journal, May and June, 1865. Also in. a separate pub- 
lication, "On Wakefulness," etc., Philadelphia, 1865 ; and again in " Sleep and 
its Derangements," Philadelphia, 1869. 

25 



360 DESCRIPTION AND TREATMENT OF INSANITY. 

and Insomnia," published eighteen years ago. The following 
case I cite from that memoir : 

A lady, aged about thirty-five, unmarried, and of rather 
delicate constitution, consulted me in regard to persistent 
wakefulness with which she had been affected for nearly a 
month. According to the account which she gave me, she 
had received a severe mental shock, which had not lost its 
influence when a subject causing great anxiety was forced 
upon her consideration. Her menstrual period, which had 
been due about ten days before she came under my notice, 
had been anticipated by a week, and the flow was prolonged 
much above the ordinary time. She had, therefore, lost a 
good deal of blood, and was, in consequence, reduced in 
strength. When I first saw her she was nervous and irri- 
table, her hands trembled violently upon the slightest exer- 
tion of their muscles, her eyes were bloodshot, the pupils 
contracted, and the lids opened to the widest possible extent. 
There was a constant buzzing in the ears, and the sense of 
hearing was much more acute than was natural. There was 
also increased sensibility of all that portion of the surface of 
the body (the skin of the hands, arms, legs, back, and breast), 
which I submitted to examination with the sesthesiometer. 
Her pulse was 98, irritable, small, and weak. 

At night all her symptoms were increased in violence. 
Her mind was filled with the most grotesque images which it 
was possible to conceive, and with trains of ideas of the most 
exaggerated and improbable character. These succeeded each 
other with a regularity so well marked that she was able to 
foresee the routine night after night. "No one," she said, 
" can imagine the weariness I feel, or the horror with which 
I look forward to the long rows of too familiar phantoms and 
thoughts which I know will visit me before morning. There 
is one set," she continued, " which always comes as the clock 
strikes two. No matter what may be passing through my mind, 
it is banished by this. It consists of a woman with very long 
hair, who sits on a rock by the sea-side, with her face buried 
in her hands. Presently a man, armed with a long sword, 
comes up behind her, and, clutching her by the hair, drags 
her to the ground. He puts his knee on her breast, and, still 
holding her hair, cuts it off and binds her with it, hand and 
foot. He then begins to pile stones on her, and continues to 
do so till she is entirely covered, notwithstanding her piercing 



INTELLECTUAL SUBJECTIVE MORBID .IMPULSES. ' 387 

shrieks, which I hear as distinctly as I do real sounds. Turn- 
ing, then, to the sea, he cries out, ' Julia, you are avenged ! 
My vow is accomplished ; come, come ! ' He then draws a 
dagger and stabs himself to the heart. He falls over the hill 
of stones he has raised, and instantly hundreds of little devils 
not more than a foot high swarm around his body, and 
finally carry it off through the air. My horror at all this is 
extreme. For more than an hour the scene is passing before 
me, and though I know it is all purely imaginary, I cannot 
shake off the terror it induces." 

I questioned this lady closely, and found that she was very 
intelligent and fully sensible of the unreality of all her vi- 
sions. I regard her case as one of passive cerebral hyperse- 
mia, and one that, if not relieved, would probably terminate 
in a more advanced form of mental derangement. 

In this and other instances that have come under my no- 
tice, there were no actual hallucinations ; that is, the patients 
did not imagine they saw with their eyes the images which 
appeared to be present, or heard with their ears the voices 
which disturbed them. The forms and the sounds were alto- 
gether mental, and were of the kind called by Baillarger 
psychical hallucinations, to which attention has already been 
given under the head of "Perceptional Insanities." 

M. Ball, 1 in a recent communication, reports several inter- 
esting cases of the affection under notice, without, however, 
apparently being aware of those cited by other authors. He 
regards them as instances of ideas being imposed upon the 
mind, and controlling it in spite of itself. To these ideas he 
gives the name of " intellectual impulsions." 

In one of these cases, a man of great intelligence, and who 
had acquired a well -deserved celebrity for his scientific works, 
could never speak in public, nor read a book in a loud tone. 
Hardly would he begin to speak ere a host of thoughts ab- 
solutely foreign to the subject rushed upon him, he lost the 
thread of his voluntary ideas, became embarrassed, and could 
not continue his remarks. If he tried to read aloud, the same 
phenomenon was reproduced with mathematical precision. 
Absorbed in the ideas which oppressed him, and which were 
entirely without relation to the text, he read, not only monot- 
onously and without expression, but incorrectly, stammer- 
ingly, and in a way like that of the most illiterate person. 

1 " Des impulsions intellectuals,' ' V EncepTiale, t. i, 1881, p. 26. 



3S8 DESCKIPUON AND TREATMENT OF INSANITY. 

Notwithstanding all his efforts, he could never succeed in 
overcoming his trouble. 

In another case, the patient, a young man of intelligence, 
of good education, and free from hereditary tendency to neu- 
rotic affections, was pursuing his studies at college, when one 
day he heard his companions talking of the mysterious fatal- 
ity connected with the number thirteen. At the same instant 
an absurd idea took possession of his mind. "If the number 
thirteen is fatal," he thought to himself, it would be deplora- 
ble if God were thirteen. Without attaching any impor- 
tance to this conception, he could not prevent himself from 
thinking of it continually, and at each instant he accom- 
plished mentally an act which consisted in repeating to him- 
self " God thirteen." He began to attach a certain cabalistic 
value to this formula, and attributed to it a preservative influ- 
ence. "I know perfectly well," he said, "that it is ridicu- 
lous that I should think myself obliged to imagine 4 God 
thirteen' every instant in order to save myself from being 
thirteen ; " but, nevertheless, the intellectual act was repeated 
without ceasing. Very soon he thought he ought to apply 
the same principle to eternity, to the infinite, and to grand 
ideas in general ; and then his life was passed in mentally 
saying, "God thirteen! The infinite thirteen! Eternity 
thirteen ! " 

In consequence of the incessant repetition of this psychi- 
cal act, the young man found it impossible to pursue his 
studies, which, until then, had been marked with success. He 
therefore went home and placed himself under medical treat- 
ment. But the continual progress of the affection was not 
arrested, and three years subsequently he was still every mo- 
ment repeating his mental prayer. Aside from the sadness 
legitimately resulting from this circumstance, there was no 
mental trouble. 

A third case is still more interesting : 

A pharmacist, thirty- six years old, an intelligent and hard- 
working man, but for a long period a hypochondriac, set out 
one day on a journey by railway, during which he lost his 
ticket. He endeavored to repair the accident by paying a 
second time for his seat, when he discovered that he had lost 
his pocket-book. The consequences of this misadventure 
were of such a character as to affect him very powerfully, so 
that he, little by little, began to look for his pocket-book at 



INTELLECTUAL OBJECTIVE MORBID IMPULSES. 389 

all times, and finally this became the chief occupation of his 
life. In the midst of an interesting conversation, during a 
delicate manipulation, or when he was serving his clients, 
the idea would flash through his mind, "I have lost my 
pocket-book." Instantly he was compelled to stop every- 
thing and look for the object in question, which he always 
found in its proper place. 

This silly idea made him ridiculous to all with whom he 
came in contact, and ended by becoming a real calamity. He 
was obliged to renounce his business, to give up a lucrative 
profession, and to retire into the country, where, however, he 
found no relief from his tormenting idea. 

A somewhat similar case is at the present time under my 
own charge. A gentleman, while driving a fast trotting-horse 
over a muddy road, was bespattered from head to foot. On 
his return to the city he changed his clothes, but the fact 
made such an impression on him that the idea constantly oc- 
curred to him in these words : " I am covered with mud ; " and 
instantly he made the motion of brushing off the soiled spots 
with his hands. . Several years have elapsed, and yet the idea 
"I am covered with mud" passes through his mind every 
moment, and he is continually making the motion of brushing 
his coat, or waistcoat, or trousers with his fingers. He knows 
he is not muddy, but the idea is there, and the motion fol- 
lows automatically. 

Dr. W. J. Morton has given me the particulars of a like 
case occurring in his experience. 

In all these cases there is probably a very limited form 
of disease in some part of the cortex. The fact that the indi- 
vidual does not accept as true the idea forced upon him, suffi- 
ciently indicates the restricted seat of the lesion. That this is 
a localized hyperemia is, I think, exceedingly probable, and 
the results of treatment based upon this hypothesis — and 
which will in a subsequent part of this treatise be fully con- 
sidered — certainly tend to support this opinion. 

/—INTELLECTUAL OBJECTIVE MORBID IMPULSES.. 

An intellectual objective morbid impulse consists of an 
idea occurring in the mind of an individual contrary to his 
sense of what is right and proper, and urging him to the per- 
petration of an act repugnant to his conscience and wishes. 
It differs from an intellectual subjective morbid impulse in 



390 DESCRIPTION AND TREATMENT OF INSANITY. 

the fact that it is directed toward the accomplishment of a 
distinct object, and that often its operation is not limited to 
the person by whom it is experienced. If yielded to, there- 
fore, the circumstance is often of such a character as to de- 
mand the serious consideration of society, for it is generally 
the case that the impulse tends to the committal of a deed of 
crime ojr violence. As in the previously described form of 
morbid impulse, there is no delusion and no necessary emo- 
tional disturbance, except such as would naturally result in 
the average man from the existence in him of an irresistible 
impulse to commit crime. Neither does the individual who 
is the subject of an intellectual objective morbid impulse ex- 
hibit any deficiency of intellect. He is perfectly aware of the 
nature of the act he is prompted to commit, and perpetrates 
it only because he is impelled thereto by a force which he feels 
himself powerless to resist. Yery often he acts with calmness 
and deliberation, and again manifests agitation and excite- 
ment. He does not for a moment lose consciousness, as does 
the epileptic, who may also commit acts of violence under 
the influence of a paroxysm ; and, when his impulse has been 
acted upon, or his purpose changed by any momentary but 
more powerful cause, he recollects distinctly all the circum- 
stances of the occasion. 

It frequently happens that the subject of an intellectual 
objective morbid impulse struggles successfully against the 
force which actuates him even when on the very point of 
yielding, or when he takes such means as experience has 
shown him are sufficient to direct him ; or the impulse disap- 
pears apparently spontaneously, or as a consequence of ap- 
propriate medical treatment. 

I have in a previous chapter related the details of several 
cases of intellectual objective morbid impulse, but the follow- 
ing will tend still further to elucidate the subject. 

Very slight causes are often sufficient to destroy or over- 
come the morbid impulse. Marc i cites the case of M. E.., a 
distinguished chemist and an amiable man, who, feeling him- 
self impelled to commit murder, and knowing his inability to 
resist, voluntarily placed himself in a maison de sante of the 
Faubourg St. Antoine. Tormented by the impulse to kill, he 
often prostrated himself before the altar, and implored the Al- 
mighty to deliver him from his atrocious impulse, the origin 
1 " Consultation medico-legale sur Harriette Cornier," etc. 



INTELLECTUAL OBJECTIVE MORBID IMPULSES. 391 

of which he could not explain. When he felt that his will 
was yielding, he went to the superintendent of the asylum and 
had him tie his hands together with a ribbon. This weak 
band was sufficient to calm the unfortunate man for a time ; 
but eventually he attempted to kill one of his keepers, and 
finally died in a paroxysm of acute mania. 

On the other hand, a man, whose case is cited by Brierre 
de Boismont, rather than yield to an impulse to kill his wife, 
which he felt was rapidly becoming irresistible, cut off his 
right arm. Honest human nature could not go much farther 
than this. 

Again, all the efforts of the affected individual are appar- 
ently unsuccessful, and the deed to which he is impelled is 
committed. I say apparently, because we never can be quite 
sure that the patient has exercised all his will-power, or 
availed himself of all those means to prevent the accomplish- 
ment of his act which ordinary reason would suggest. When 
he effectually resists, there are not wanting those who will 
declare that the case is not one of morbid impulse, while, 
when he yields at once or eventually, these same persons will 
just as strongly affirm that the impulse was irresistible. Sev- 
eral cases have come under my observation in which patients 
have confessed to me that they have had impulses to commit 
various kinds of crimes which they have been barely able to 
resist. These people have passed through life attending faith- 
fully to their several duties, and entirely unsuspected of con- 
tending with themselves in so terrible a manner. 

I was once consulted by a young man for symptoms indi- 
cating the existence of cerebral hyperemia. He had pain in 
his head, dizziness, and was unable to sleep. He informed me 
that he had been for several months constantly troubled by a 
force, which was inexplicable to him, to kill a friend who was 
employed in the same office with him. Upon one occasion he 
had gone so far as to secretly put strychnia into a mug of ale 
which he had invited the young man to drink ; but just as the 
intended victim was raising the vessel to his lips, he had, as if 
by accident, knocked it out of his hand. Every morning he 
had awakened with the impulse so strong upon him that he 
felt certain he would carry it out before the day closed ; but 
he had always been able to overcome it. 

This young man reasoned perfectly well in regard to his 
impulse, and very candidly admitted, and I entirely agreed 



392 DESCRIPTION AND TREATMENT OF INSANITY. 

with him, that, if he had yielded and committed the murder, 
he ought to have been punished to the full extent of the 
law. 

The following extract from a letter, received several years 
ago, is likewise to the point : 

" In the New York Sun, of the 30th instant, I noticed the 
proceedings of the Medico-Legal Society, in the College of 
Physicians and Surgeons, on emotional insanity, etc., and I 
was impressed particularly with your remarks on 'Morbid 
Impulse.' Some two weeks since, I was at work in my gar- 
den with a spade, and one of my little girl children, just three 
years old, came in where I was, and I was suddenly seized 
with an impulse to kill the child with the spade that I was at 
work with, and, in order to prevent my doing so, I had to 
make her leave the garden. Now, I love this child better than 
I do the apple of my eye, and why I was seized with that im- 
pulse I can't say. Since that time I have been feeling strange, 
and I am afraid to trust myself with my own family, though 
I know perfectly well what I am doing, and only feel actu- 
ated by these impulses. I have consulted a physician, and 
he laughed at me. If you can suggest any remedy for these 
strange impulses, I will pay you what you charge, and will 
consider that you have done me a favor that will cause me 
to bless your name forever. I don't consider that I am in 
any danger of murdering any one just yet, but the idea of 
such a thing is horrible, and I fear it may grow on me unless 
remedied." 

In my reply, I called his attention to the admitted fact 
that he had his impulse under control ; that he was able to 
reason calmly and intelligently in regard to it ; that he had 
applied to me for advice, and that I urged him without delay 
to place himself under the restraint of an asylum. I further 
told him that, if he disregarded this advice, and finally 
yielded to his impulse, he would be fully as guilty of murder 
as though he had killed his child through deliberate malice, 
and that he ought to be just as surely executed as any other 
murderer. 

An instance of the slightness of the cause often sufficient 
to arrest the course of an impulse has already been given. 
Such cases are by no means rare, and some notable ones have 
been recorded. Thus : 

On the 10th of November, 1854, as related by M. De- 



INTELLECTUAL OBJECTIVE MORBID IMPULSES. 393 

vergie, 1 a young man, aged nineteen, the son of a prominent 
merchant of Bordeaux, dined with his father, to whom he 
was much attached, and his step-mother, whom he had re- 
garded with gradually increasing aversion for several years. 

The dinner passed without any unusual incidents till des- 
sert, when Jules , the young man in question, left the 

table and repaired to the drawing-room to warm himself. Not 
finding a fire kindled, he went to his own chamber, took his 
fowling-piece, and started out for a stroll through the country, 
as was his custom. He had not left the house, however, be- 
fore the idea of suicide, which had haunted his mind for sev- 
eral weeks, suddenly recurred to him, and was as suddenly 
changed into the thought of killing his step-mother. 

Without stopping an instant, he threw aside his fowling- 
piece, and, going to his brother's room, took two pistols, which 
had been loaded three weeks. He had pistols of his own 
which he might have taken, and which had been charged only 
the day before. 

He descended to the dining-room, approached his step- 
mother, who was still at the table with his father, and, point- 
ing the pistol at her head, discharged it with instantly fatal 
effect. 

Madame X. fell to the floor, and the young man, recoiling, 
rested motionless against the wall. His father rose to seize 
him, but, a temporary feeling of self-preservation being 
aroused in Jules, he fled across the kitchen through the midst 
of the terrified domestics, and escaped from the house, ex- 
claiming, "I am a madman, an idiot ! I have killed my step- 
mother ! " 

He soon, however, changed his mind, and surrendered 
himself to the commissary of police, to whom he related all 
the particulars of the crime. 

Before and until the murder, the life of this young man 
had been exemplary. He had performed his duties in the 
counting-house of his father with assiduity, and was an excel- 
lent son and brother. Though rich, he had studiously avoided 
dissipation of every kind. 

Such were the obvious features of the homicidal act. Jules 
was tried before the Imperial Court at Paris. Calmeil, Tar- 
dieu, and Devergie, the most eminent alienists in France, tes- 

1 " Oti finit la raison? Oft. commence la folie? " " Memoires de l'academie 
imperiale de medecine," t. xxiii, p. 1, Paris, 1859. 



394 DESCRIPTION AND TREATMENT OF INSANITY. 

tified in favor of the insanity of the prisoner, and he was ac- 
quitted on that ground. 

In his own account of the act he said : 

" When I ascended to my room on the day of the crime, I 
was not thinking of anything. I should not have gone up- 
stairs if I had found a fire in the drawing-room. When I 
reached my room, having no evil intentions, the notion of sui- 
cide possessed me ; then, my thoughts taking another direc- 
tion, I threw aside my fowling-piece, ran to my brother's 
chamber, armed myself with two pistols, and went back to 
the dining-room, actuated by I know not what force, which 
dragged me in spite of myself. If my father had ad- 
dressed to me one word when I entered the dining-room, 
whatever it might have been, I would not haw killed my 
step-mother " 

Five years subsequently, Jules, several of whose ancestors 
had been insane, committed suicide at his step-mother's 
grave. 

A lady, several years ago, was brought to me by her hus- 
band for advice in regard to her mental condition. She told 
me her own story as nearly as possible in the following words, 
which I transcribe from my note-book : 

" I had been feeling quite badly for several days, had not 
slept well, and was suffering from slight but continuous pain 
in the head, and vertigo. Moreover, I had some little confu- 
sion of mind, as shown by the fact that I could not collect 
my thoughts, and called things often by their wrong names. 
I was not depressed in spirits, though I felt uncomfortable 
enough. This morning I awoke after a particularly restless 
night. I went to the window, drew aside the curtains, and 
looked down into the street. A slight snow, followed by rain, 
had fallen, and the sidewalks were slushy and slippery. All 
at once, with a suddenness and force that were overwhelming, 
the idea came into my head to throw myself from the window. 
I opened it hastily, and was in the act of plunging down head 
foremost, when my attention was attracted by a boy, with a 
basket of bread on his arm, slipping on the pavement and 
falling in the street. I burst into a hearty laugh ; my impulse 
was gone. I closed the window, gave a cry, and fell to the 
floor in a fainting condition. I recovered consciousness in a 
moment or two, and found my husband bending over me. I 
recollected everything that had happened. The print of my 



INTELLECTUAL OBJECTIVE MORBID IMPULSES. 395 

hands was still in the snow on the window-sill, and the boy 
had really fallen as I had described. Since then I have been 
feeling much better, but I am afraid of myself, for I don't 
know what impulse may come upon me next." 

It will be seen, therefore, that an impulse of the kind 
under consideration may be sudden, and may exhaust itself 
by a single occurrence, or it may be continuous, lasting, with 
more or less intensity, for weeks, months, or even years. It 
may then disappear without its ever having been fulfilled, or 
it may be acted upon, and may then either be repeated or 
vanish, or it may result in the patient passing into a more 
generalized type of insanity. 

An intellectual objective morbid impulse is sometimes ex- 
cited by a suggestion which the individual suddenly receives. 
The action of this principle is well shown in the following in- 
stances : 

A young man, a member of a highly respectable family, 
consulted me for what he very properly thought was a kind 
of insanity. It appeared that a few weeks previously, while 
walking down Broadway, he had been struck with the ap- 
pearance of a lady in front of him who wore a very rich 
black silk dress. Suddenly the impulse seized him to ruin 
this dress by throwing sulphuric acid on it. He, therefore, 
stopped at an apothecary's shop and purchased a small phial of 
oil of vitriol. Hastening his pace, he soon overtook the lady, 
and, walking by her side, he managed in the crowd to empty 
his phial over her dress without being perceived. He derived 
so much satisfaction from this act that he resolved to repeat 
it at once on some other woman. He, therefore, purchased 
another supply of vitriol, and, singling out a lady better 
dressed than others around her, poured the contents of the 
phial over her dress, and again escaped detection. He then 
went home, and, reflecting upon what he had done, determined 
to persevere in the practice ; but a night's rest put him in a 
healthier frame of mind, and he concluded to abandon the 
idea. Indeed, he was so distressed by what he had done 
that he wrote out an advertisement for the newspapers, in 
which he requested the ladies whose gowns he had spoiled to 
reply through the same channel, giving their residences, so 
that he might compensate them for the losses he had caused 
them to sustain. But on his way to the newspaper offices he 
again felt the impulse, at the sight of a handsome silk gown, 



396 DESCRIPTION AND TREATMENT OF INSANITY. 

to throw vitriol on it, and again he purchased a supply, and 
repeated the acts of the day before. 

He now began to consider more fully than he had yet done 
the nature and consequences of his conduct, and the next 
morning came to me for advice. He .stated very frankly 
his entire conviction that his acts were in the highest degree 
immoral and degrading, but expressed his utter inability to 
refrain from their perpetration. 

"A handsome dress," he said, "acts upon me very much 
as I suppose a piece of red cloth does on an infuriated bull : 
I must attack it. The bull uses his horns, while I use vitriol. 
I do not know why the idea ever came into my head. I cer- 
tainly never would have conceived of such a thing if I had 
been blind. I was altogether excited by the sight of that 
handsome silk dress the first day, and it was impossible for 
me to resist after the idea had once had a lodging in my mind. 
I have often seen fully as handsome dresses in the street be- 
fore, but never previously was the sight followed by such an 
impulse." 

After the most careful examination, I could discover no 
evidence of disease, except in the one point of wakefulness, 
with which he had suffered for several months past. I there- 
fore prescribed bromide of calcium for him, and insisted on 
his removing himself from further temptation by taking a 
sea voyage on a sailing vessel upon which there were no 
women passengers. He went to sea in a fishing schooner, and 
returned in three or four months perfectly free from his mor- 
bid impulse. 

A gentleman, who came about once a week to consult me 
for cerebral congestion, the result of excessive application to 
business, and who lived in a neighboring town, informed me 
that during his journeys by rail he invariably experienced an 
impulse to throw himself from the train. Finally he was so 
strongly impelled that he stated the case to an acquaintance 
in the car, and begged him to sit near him and restrain him 
if he made any such attempt. After that he never came with- 
out bringing a friend with him, who had instructions not to 
lose sight of him for an instant. In telling me of his impulse, 
he described it as almost overwhelming, and that it seemed to 
be excited by the rapid motion, and by the fact that he had 
heard of people throwing themselves from railway trains. 

It is well known that many persons standing on great 



INTELLECTUAL OBJECTIVE MORBID IMPULSES. 397 

heights experience an impulse to jump off. So many indi- 
viduals committed suicide by leaping from the Colonne Ven- 
dome and the Arc de Triomphe in Paris, and from the Duke 
of York' s monument in London, that precautions had to be 
taken to prevent further acts of the kind. 

Marc relates the case of a nurse who felt the impulse to 
murder the infant she took care of whenever she saw its 
naked skin. She threw herself on her knees before her mis- 
tress and begged to be discharged, declaring that the white- 
ness of the child's skin excited her to murder it, and that 
she could not longer resist the impulse. 

Several years since, I had under my charge a lady who, 
whenever she saw the naked shoulders of a young child, felt 
an impulse, which she declared she could not resist, to bite 
the skin. She had thus inflicted very disagreeable wounds 
on the children of her friends, and was finally arrested on the 
charge of assault ; but the matter was hushed up on her prom- 
ise to abstain from such conduct in the future, and she kept 
her promise. 

Morbid impulses to commit violent acts are often developed 
by the sight of a suitable weapon for the purpose. Persons 
have hanged themselves on the suggestion excited by the 
sight of a rope ; others have committed murder or suicide 
from seeing knives, pistols, etc., lying in inviting situations. 
A lady, seeing a phial labelled "nitric acid" on a table in my 
consulting-room, seized it, and, putting it to her lips, would 
have swallowed the contents if I had not fortunately per- 
ceived her in time and knocked it from her hands. As it 
was, she only succeeded in spoiling an elegant gown. 

Even a word spoken in jest may, under certain circum- 
stances, be sufficient. Dr. Oppenheim, of Hamburg, having 
received for dissection the body of a man who had committed 
suicide by cutting his throat, but who had done this in such 
a manner that his death did not take place until after an in- 
terval of great suffering, jokingly remarked to his attendant : 
"If you have any fancy to cut your throat, don't do it in 
such a bungling way as this ; a little more to the left here, 
and you will cut the carotid artery." The individual to whom 
this dangerous advice was given was a sober, steady man, 
with a family, and a comfortable subsistence. He had never 
manifested the slightest tendency to suicide, and had no mo- 
tive to commit it. Yet, strange to say, the sight of the corpse 



398 DESCRIPTION AND TREATMENT OF INSANITY. 

and the observation made by Dr. Oppenheim suggested to 
his mind the idea of self-destruction, and this took such firm 
hold of him that he carried it into execution, fortunately, 
however, without profiting by the anatomical instruction he 
had received, for he did not cut the carotid artery. 

Closely allied to suggestion, and perhaps a more powerful 
cause of morbid impulse of the species under notice, is imita- 
tion. Thus, many crimes have been committed by persons 
who have had the impulse excited by reading accounts of the 
trials of other persons, or the detailed recitals of all the par- 
ticulars of offences which the age requires the public press 
to contain. Epidemics of murder, suicide, arson, and other 
crimes are thus produced. 

"Some years ago," says Dr. Forbes Winslow, 1 "a man 
hung himself on the threshold of one of the doors of the 
Hotel des Invalides. No suicide had occurred in the estab- 
lishment for two years previously ; but in the succeeding 
fortnight five invalids hung themselves on the same cross-bar, 
and the governor was obliged to shut up the passage." 

Epidemics of suicide spread, according to Plutarch, among 
the women of Miletus, and, as is well known, in later days, 
among the women of Marseilles. 

A careful study of the cases of suicide recorded in the 
daily newspapers shows that they are to a great extent influ- 
enced in character by the principle of imitation. A case of 
suicide by Paris green is published, and straightway half a 
dozen others due to this poison are the result. Or a man or 
woman jumps from a ferry-boat while it is crossing the river, 
and then this mode becomes the fashion for a while, to be fol- 
lowed in its turn by some other method. 

When I was a medical student, a young gentleman from 
Georgia was on one occasion dissecting the same body that I 
was. He had drawn one of the lower extremities as his part of 
the subject, and he was assiduous and careful in his work. So 
far as my observation extended, he did not differ essentially 
from other medical students. He was cheerful in disposition, 
and gave no evidence whatever of mental derangement, or 
even of excitement or depression of mind. One morning we 
were told that he had been found dead on the floor of his bed- 
room. An examination showed that he had divided his femoral 
artery, and had died of hemorrhage. It was then ascertained 

1 " The Anatomy of Suicide," London, 1840, p. 120. 



INTELLECTUAL OBJECTIVE MORBID IMPULSES. 399 

that lie had the evening before received a letter which had 
apparently caused him much unhappiness. 

Now, suicide by division of the femoral artery is certainly 
a very unusual mode of self-destruction. I doubt if any case 
of the kind had previously occurred in New York. Yet 
within a week there were two others, one of which was Horace 
Wells, the alleged discoverer of the anaesthetic properties of 
sulphuric ether. 

Here we have the principle of suggestion acting on the 
first victim, and then that of imitation on the others. 

Imitation is of more force when the intellect is less fully 
developed. Even in the normal condition we find it more 
strongly exercised in women and children than in adult men. 
In the latter, the influence may be so powerful that actual 
disease is acquired. Thus, a child imitates the movements of 
another affected with chorea, or with stammering, and imme- 
diately contracts the disorder. Even squinting has been pro- 
duced in this manner. 

A lady received such a vivid impression at seeing her maid 
throw herself down a well that she never passed a well with- 
out feeling a strong impulse to throw herself into it. 

An idiot, having killed a pig, felt impelled to kill a man, 
and obeyed the impulse on the first one he met. 

A melancholic person was present at the execution of a 
criminal, and was immediately seized with an impulse, of 
which he was fully conscious, and could scarcely resist, to 
murder some one. 

A child six years old strangled its younger brother. The 
father and mother, entering the room the moment the act was 
in process of accomplishment, demanded the cause. The 
child threw itself weeping into their arms, and answered that 
it was imitating the devil, whom it had seen strangle Punchi- 
nello. 

Such cases as these, though not all of them, examples of 
intellectual objective morbid impulse, are at least of value if 
they cause us to recognize the force of the principle of imita- 
tion, and to render less public than they are now the slaugh- 
ter of animals and the executions of criminals. 

Intellectual objective morbid impulses have, according to 
their character, been classified as homicidal mania, or the im- 
pulse to commit murder ; suicidal mania, or the impulse to 
perpetrate self-destruction ; pyromania, or the impulse to burn 



400 DESCRIPTION AND TREATMENT OF INSANITY. 

houses and other things ; kleptomania, or the impulse to steal, 
and so on. The mere object of the impulse should not, in 
my opinion, be sufficient to elevate the act to the dignity of a 
distinct species of insanity. The names, however, are useful, 
as explanatory of the main symptom exhibited by the patient. 

Again, many of the cases of each of the varieties men- 
tioned are not instances of intellectual, but of emotional or 
volitional morbid impulse, or of epileptic mania, examples 
of which will be subsequently brought to the notice of the 
reader. The distinction of the intellectual objective morbid 
impulse being that it arises in consequence of an idea the ful- 
filment of which is in direct relation with that idea, whereas 
the impulse due to deranged volition or emotion has no such 
starting-point, still less has that which arises from epilepsy. 

Intellectual objective morbid impulse is more apt to occur 
in persons who possess what has been called the "insane tem- 
perament " than in those of equally balanced minds. It may 
develop into some more pronounced and obvious form of in- 
sanity, or it may become continuous in the individual. Gen- 
erally it is unaccompanied by illusions or hallucinations, but 
there are cases in which one or the other of these condi- 
tions of perceptional derangement has been the exciting 
cause. 



CHAPTER V. 
in. 

EMOTIONAL INSANITIES. 

The emotions are in most persons difficult of control, but 
they may acquire such an undue and morbid prominence as 
to dominate over the intellect and the will, and to assume the 
entire mastery of the actions in one or more respects. This 
effect may be produced suddenly, from the action of some 
cause capable of disturbing the normal balance which exists 
between the several parts of the mind, or it may result from 
influences which act slowly but with gradually increasing 
force. In neither case is there necessarily either delusion or 
error of judgment, but it very generally happens that the in- 
tellect sooner or later becomes involved. 



EMOTIONAL MONOMAEIA. 401 

Within certain limits, all persons are influenced in their 
thoughts and actions by the emotions they experience. But, 
as these are generally of very fleeting and changeable charac- 
ter, the individual who relies upon them for his guides is, 
of course, as fickle and unstable as the emotions themselves. 
But cases occur in which an emotion not only becomes inten- 
sified in power, but assumes a permanency altogether incon- 
sistent with the normal condition. Such a state is embraced 
under the designation of emotional insanity. 

The emotional insanities, therefore, are those forms of 
mental derangement in which the aberration of mind is chiefly 
exhibited by disturbance in the normal action of some one 
or more of the emotions. 

a — EMOTIONAL MONOMANIA. 

The number of forms of emotional monomania is only lim- 
ited by the number of the emotions, though some are very 
much more liable to derangement than others. As the term 
implies, emotional monomania refers to aberration of a single 
emotion. 

The subjects of emotional monomania, usually before the 
occurrence of the most pronounced symptoms of the affec- 
tion, evince more or less disturbance of the emotional system, 
either as a whole or in part. Thus, it was observed of a 
young lady, who had, so far as was known, no hereditary ten- 
dency to insanity, but who was nevertheless very impression- 
able, that she became more than ordinarily scrupulous in her 
dress. She would spend hours in the arrangement of her 
hah-, the care of her finger-nails, the tying of ribbons, fast- 
ening of brooches, etc. This conduct, though it attracted the 
attention of her mother and sisters, was rather the subject of 
joke than of any apprehension relative to the integrity of her 
mind. She was laughed at for wasting so much of her time 
in personal adornment, as previously she had not been espe- 
cially noted for neatness either of person or attire. This con- 
tinued for several months, and then she began to talk about 
her beauty and attractions, and of the looks of admiration 
which were cast at her as she walked down the street. There 
was one gentleman who she declared had followed her home, 
and for whom she expressed great admiration. On inquiry, 
it was ascertained that the person to whom she referred had 
not followed her home, but that she had spoken to him, 

26 



402 DESCRIPTION AND TREATMENT OF INSANITY. 

and had requested him to accompany her to the door of her 
residence, as it was getting dark and she was afraid. This 
he had declined to do, taking her, from her appearance and 
manners, to be no better than she should be. This episode 
resulted in her being sent to live with an aunt who resided 
in the country several miles from any town, and where it was 
thought she would have no opportunity to indulge in what-- 
appeared to be newly developed proclivities. But in this her 
friends were mistaken. She began to write letters to the 
gentleman to whom she had spoken in the street, and whose 
name and address she had ascertained, and three or four 
times a day despatched, with the aid of a servant-maid, a note 
to him, in which she either lauded him to the skies, as her 
knight, her Chevalier Bayard, her Admirable Crichton, who 
would, she did not doubt, come to her rescue and make her 
his wife ; or she described her own devotion and the anguish 
she was enduring at being separated from him ; or she abused 
in very outrageous language the hyena — her father — the she- 
dragon — her aunt — who had conspired to take her away from 
her " best beloved." 

Suddenly she ceased talking of the object of her infatua- 
tion, and discontinued writing him letters. It was fondly 
hoped that she had abandoned her fancy, and congratulatory 
messages were accordingly sent to her father. Her conduct 
in other respects seemed to have undergone an improvement. 
She requested her aunt to mark out a course of historical 
reading for her, and for several days was rarely seen without 
a book in her hand. But one morning it was ascertained that 
she had taken her departure. She had left her bedroom by a 
window, had walked along the roof of a veranda to the edge, 
and had then dropped upon a flower-bed immediately under. 
She had then walked to the railway-station, a distance of two 
miles, had gotten aboard of a "milk train," and had arrived 
in New York at four o' clock in the morning. She had then 
taken a cab, and had caused herself to be driven to the hotel 
of the gentleman on whom she had fastened her affections. 
Here she stated at the office that she was his sister, and had 
arrived with important information, which it was necessary 
he should at once receive. She waited for him in the public 
drawing-room, and, on his entering the apartment, threw her- 
self at his feet, exclaiming : " See what I have done for you. 
I have left everything — house, riches, father, and all— for you ! 



EMOTIONAL MONOMANIA. 403 

Do you now doubt my love ? " The gentleman, who was in 
reality worthy of the name, at once recognized her as the lady 
who had addressed him in the street and as his correspond- 
ent. She had signed her letters "Stella," and he had not 
even taken the trouble -to ascertain her name. Now, however, 
perceiving the real state of the case, he determined to act 
promptly ; so sending for a lady friend, who lived near by, to 
accompany them, he took the yonng lady as fast as a cab 
could travel to her father's house. In a few minutes the 
situation was explained to the astonished parent, and a short 
time afterward a telegram from the aunt arrived with its su- 
perfluous information. 

Recognizing the fact that his daughter's mind was de- 
ranged, the father brought her to me that same morning. 

On entering my consulting-room, she began in the most 
voluble manner to explain her conduct. " I am in love with 

Mr. ," she said. " He is the noblest and the best man 

there is in the world, and I have selected him as my hus- 
band. If he were here now, he would tell you how devotedly 
I am attached to him. If he does not love me now, he will 
love me as soon as he has had the opportunity of making my 
acquaintance. Of course, all this fuss, merely because I left 
my aunt's house last night, is calculated to prejudice him 
against my family ; but I can soon make that all right if I am 
allowed the opportunity of a few minutes' conversation with 
him. I don't understand why I am brought to see you. I 
have no need of a physician ; I am in perfect health. I am 
simply in love, and nothing, oh, nothing!" she continued, 
clasping her hands together and rolling her eyes to the ceil- 
ing, u will ever make me renounce my noble , my lord, 

my king, my pope and emperor." 

"Take me to him at once," she resumed, addressing her 
father. " You have no right to separate us. I am of lawful 
age, and I have a right to marry whom I please. Do you 
know what I will do if you continue to keep us apart % I will 
kill myself ; I will take poison, and the death of your daugh- 
ter will rest heavily on your heart." It is impossible to de- 
scribe the tragic air with which she walked up and down the 
floor while speaking these words, and the emphasis and pas- 
sion with which they were enunciated. 

I endeavored to quiet her, and so far succeeded that in a 
few minutes I had obtained important information relative to 



404 DESCRIPTION AND TREATMENT OF INSANITY. 

her physical and mental condition. In fact, on her father 
leaving the room, she spoke with entire freedom on all the 
points upon which I questioned her. 

I found that, though she had no pain in the head, she suf- 
fered almost constantly from a feeling of constriction, as 
though a tight band pressed upon her forehead. She had at 
times had flashes of light before the eyes, and there was 
tinnitus aurium to a disagreeable extent. She slept badly, 
and had frightful dreams, alternating with others in which 
she experienced the delights of a domestic life with the man 
she loved. Her menstruation w^as regular in every respect, 
and there was no suspicion of uterine or ovarian disease. 
During the whole of her conversation with me she did not 
give expression to a single libidinous thought, if she had such, 
and subsequent inquiry established the fact that at no time 
had there been any apparent exaltation of the sexual feeling, 
however much it may have been the basis of her emotional 
derangement. Neither did I detect the existence of any de- 
lusion or other aberration of the intellect. So far as her ideas 
were concerned, there seemed to be the most perfect integrity. 
She admitted unhesitatingly that her conduct had not been 
proper. "I know," she said, "that I ought not to have 

spoken to in the street ; that I ought not to have written 

to him ; that I ought not to have left my aunt's house in the 
night ; that I ought not to have gone to his hotel ; but this 
is not a question of right. I love him, and that is the end of 
it. There is no use talking about the matter, I love him." 

Up to this time there had been no hallucinations ; but 
while in conversation with me she suddenly stopped talking, 
and seemed to be listening attentively, as though she heard a 
sound. A pleased expression passed over her countenance, 

and she exclaimed : " I hear ' s voice in the next room. 

He wishes to see me. Don't attempt to stop me, for I will go 
to him." She opened the door of the adjoining apartment. 
There was no one there but her father. "I thought I heard 

calling my name," she continued, "but I must have been 

mistaken." 

I advised that a strong and sensible nurse should be pro- 
cured, and that the patient should be treated at her own 
home. A suite of rooms in the upper part of the house was 
set apart for her and her attendant. She was taken out to 
drive every day. Her bowels, which had been obstinately 



EMOTIONAL MONOMANIA. 405 

constipated, were kept freely open with aloetic purges, and 
the bromide of sodium was administered in large doses. She 
soon became calmer, began to sleep well, lost the sense of 
tightness about her head, and gradually ceased to talk of Mr. 

and of her love for him. There was still, however, a 

certain exaltation of feeling, which would, I thought, require 
but a slight exciting cause to develop it into a higher state of 
excitement, and I therefore recommended foreign travel. She 
is now in Europe, and at last accounts was rapidly regaining 
her normal mental condition. 

It often happens that the subjects of emotional mono- 
mania of the variety under consideration do not restrict their 
love to any one person. They adore the whole male sex, and 
will make advances to any man with whom they are brought 
into even the slightest association. If confined in an asylum, 
they simper and clasp their hands, and roll their eyes to 
the attendants, especially the physicians, and even the male 
patients are not below their affection. There is very little 
constancy in their love. They change from one man to an- 
other with the utmost facility and upon the slightest pretext. 

"I was very much in love with Dr. ," said a woman to 

me in an asylum that I was visiting, " but he was late yester- 
day in coming to the ward, and now I love you. I will never 
love any one but you. You will come often to see me, won' t 
you ? " While she was speaking, the superintendent entered 
the ward. " Ah, here comes my first and only love," she ex- 
claimed. " Why have you stayed so long away from your 
Eliza?" 

It is quite commonly the case that prominent public char- 
acters — men and women — are annoyed by erotomaniacs, who 
follow them from town to town and make every effort, per- 
sonally and by letters, to obtain interviews. There is scarcely 
a celebrated actor or actress who has not been the subject of 
the passion of one or more of these people. Sometimes it 
happens that failure to secure recognition causes a change in 
the character of the emotion, and attempts at murder or other 
acts of violence are committed. 

On the 8th of November, 1816, while Miss Francis Kelly 
was performing the part of Nan in the farce of " Modern An- 
tiques," at the Drury Lane Theatre, London, the audience 
and the lady were thrown into a state of alarm and consterna- 
tion by the report of a pistol, fired at her by a man who sat 



406 DESCRIPTION AND TREATMENT OF INSANITY. 

in the front row of the pit. He was at once arrested, and 
gave his name as George Barnett. 

When Miss Kelly was informed of his name, she immedi- 
ately recollected him as a person who had addressed her 
several love-letters, which she had disregarded. Barnett 
was an attorney's clerk, and he had been for several months 
sending almost daily, to the object of his devotion, amatory 
epistles, sonnets, acrostics, and other professions of his love. 
As no attention was paid by the lady to these effusions, he 
took the resolution of killing her "upon," as the relator 
says, " the very altar where her charms had kindled his 
ardent flame ; and that, if he was to be debarred the pos- 
session of her, she should never become the prize of a hap- 
pier rival." 

Barnett was tried at the Old Bailey, acquitted on the 
ground of insanity, and confined in Bethlehem Hospital for 
the Insane. While there he composed an ode to Miss Kelly, 
but finally lost his love for her, and spent his time in address- 
ing amatory poems to every young lady whose name and resi- 
dence he could discover. 1 

It is necessary to distinguish the condition under consider- 
ation from nymphomania or satyriasis. In emotional eroto- 
mania there is very little tendency to obtrude indecent acts or 
words into the conduct or language, whereas in the two other 
affections obscenity is the principal characteristic. Doubtless 
it is true, as already intimated, that the genesic instinct is at 
the bottom of erotomania, but it is so well kept in the back- 
ground as rarely to become a prominent feature. Indeed, in 
most cases there is a kind of mystical exaltation of manner, 
action, and language present, that effectually conceals any 
lower sentiment that may exist. Some of the female sub- 
jects of erotomania who have come under my notice have 
evinced toward the objects of their passion the highest kind 
of devotional feeling, such as might be entertained by a mor- 
tal for an angel. But, even in these cases, the sexual instinct 
still exists and constitutes the foundation on which the ex- 
alted passion rests. It is well known that the fact of the sex- 
ual orgasms occurring during sleep to nuns in the middle 
ages led them to the belief that they had been visited in the 
night by heavenly beings, with whom they had had sexual 

1 " Sketches in Bedlam ; or, Characteristic Traits of Insanity," by A Constant 
Observer, London, 1823, p. 64. 



EMOTIONAL MONOMANIA. 407 

relations, and for whom they forever afterward entertained 
the most intense mystical though physical love. 

The emotions of pride and vanity are often the subjects of 
derangement to such an extent as to constitute a marked type 
of mental derangement. It is usually the case with the sub- 
jects of emotional disturbance of the kind in question that 
there is very little or nothing in them which can justify even 
a moderate amount of pride or of vanity, and hence there is 
a condition present nearly approaching delusion, but still not 
in relation to a matter of fact. The individual who, for in- 
stance, is insane on the subject of his ancestry, and in regard 
to which he exhibits the most pronounced pride and ridicu- 
lous vanity, need not really believe that he is descended from 
a long line of kings or other notable people. He affects to 
believe it, and for the time being may half persuade himself 
that he actually is a great man, or ought to be. His derange- 
ment comes from the fact that his intense selfishness and ego- 
tism cause him to look with the utmost degree of partiality 
upon everything connected with himself, and he thinks, there- 
fore, that if his ancestors were not great people, they ought to 
have been, and he tells those who will listen to him that they 
really were such. 

Occasionally, however, the emotion of pride or vanity is 
developed upon an actual fact to such an abnormal extent as 
to constitute veritable insanity. I was once consulted in the 
case of a lady who was in such a condition. She was a Ger- 
man, and some service of her husband to a German potentate 
had resulted in his being created a baron, she becoming a 
baroness. This so affected the emotions of pride and vanity 
that she refused to sit at the same dinner-table with untitled 
people, or even to live in the same house with them. She in- 
sisted on her husband going to Germany to reside, where, as 
she said, " proper respect was paid to rank." She dressed 
herself on all occasions in the most elaborate style, and with- 
out the slightest regard to expense, and she strutted about 
with all the airs and graces of an opera oouffe princess. And 
yet with all this there was no marked derangement of the 
intellect. There were no delusions ; she talked in a very ra- 
tional manner on all subjects, and even on that of her newly 
acquired dignity betrayed only a moderate amount of exalta- 
tion so far as her speech went. I saw her but once, and then 
she was surrounded by books on heraldry, out of which she 



408 DESCRIPTION AND TREATMENT OF INSANITY. 

was endeavoring to construct a coat of arms ; and, though it 
was ten o'clock in the morning, she had diamonds as large as 
filberts in her ears and on her breast, and a sort of diadem on 
her head, which she gravely informed me was the coronet of 
a baroness. 

As Alibert * says, man is vain of everything — of the father 
who has begotten him, of the country in which he was born, 
of the wealth he has inherited, of the clothes he wears, of the 
roof that shelters him, of the carriage he drives, of the woman 
he loves, of the God he worships, of the master he serves, of 
the friend with whom he associates, of the man who salutes 
him, of the one who speaks to him and the one who listens 
to him. However much we may laugh at the vain man, his 
vanity is not inconsistent with perfect sanity. It is only when 
the emotion runs away with him, so to speak, as it did with 
the baroness, that we can call him insane. And it is the 
sudden change, as a consequence of an insufficient cause, that 
forms the chief element in our diagnosis. In such cases, there 
is always, as there was with her, more or less mental weak- 
ness, and there is also present a tendency to a still further 
involvement of the intellect. 

Descuret 2 gives the following case, illustrative of the ex- 
tent to which morbid vanity may carry the individual. Emilie 
B., of a lymphatic temperament, was attacked during her 
infancy with tinea capitis, which denuded of their hair sev- 
eral places on her scalp. She had hardly passed her fifteenth 
year when she plunged into the world of fashion, where the 
emotions are constantly finding new excitations. Here she 
heard the praises that are bestowed on the graces and the 
beauty of women, and the advantages they receive from a fine 
toilet. She was herself not without some charms, and, to 
make them of the utmost value, she indulged her vanity to 
the fullest extent, in which she was encouraged by a mother 
who idolized her. Nevertheless, the small triumphs she ob- 
tained were poisoned by the remembrance of her infirmity, 
which, although she could by the devices of the hair-dresser 
conceal from others, was a torment to her even in the midst of 
her pleasures. 

She had hardly arrived at the age of eighteen when her 
mother died. Being thus left to herself, she took to reading 

1 "Physiologie des passions," Paris, 1825, t. i, p. 47. 

2 " La medecine des passions," etc., Paris, I860, t. ii, p. 212. 



EMOTIONAL MONOMANIA. 409 

romances and other books, which led her on to the still fur- 
ther development of her vanity, and she made many efforts to 
make her hair grow on the places that were bald. All these 
being unsuccessful, she went to Paris to consult eminent der- 
matologists, but even there failure resulted. One day at din- 
ner a gentleman was loud in his admiration of the magnifi- 
cent hair of a lady of his acquaintance. She was much 
chagrined at this, but managed to conceal her emotion, and 
the next day assisted her sister-in-law — the lady with the 
splendid head of hair — in making her toilet. She insisted on 
dressing the hair, and handled it with as much sang froid as 
she could command. But soon she was overcome, and, being 
no longer able to refrain from tears, she escaped from the 
room, and, going to her own chamber, hanged herself to the 
bed-post, where she was soon afterward found dead. 

The emotion of avarice is one which is frequently devel- 
oped to a point sufficient to cause it to exercise a morbid 
power over the rest of the mental organism, and to constitute 
a state of insanity. The case of John Elwes is one in which 
avarice was carried to such an extent as to come within the 
bounds of mental alienation. This man was immensely rich 
for the period at which he lived, having a fortune of nearly 
a million pounds sterling. He owned a large part of London, 
and built many houses, thereby largely increasing his income. 
He lodged in the corner of one of his houses, which was so 
badly situated that he could not rent it, and his only furniture 
consisted of two broken-down chairs and a common deal table. 
He kept no servant, and often he was in danger of dying for 
want of nutritious food. His clothes were composed of old 
tattered garments which he found at second-hand clothing 
shops, and which he wore as long as they would hang to- 
gether. His wig he had picked up out of a gutter into which 
a beggar had thrown it. He would not allow his shoes to be 
cleaned, because rubbing them, as he said, would make them 
wear out sooner. One day he was kicked by a horse, but he 
would not, on account of the expense, send for a surgeon. 
This piece of economy cost him dear, for he was in danger of 
losing his leg through gangrene, and many visits of a surgeon 
were required. He ate things which the lower animals would 
not have eaten. A piece of rotten meat delighted him, for he 
could buy it cheap or get it for nothing. He used neither 
fire nor candle, and, rather than hire a cab or buy an umbrella, 



4:10 DESCRIPTION AND TREATMENT OF INSANITY. 

lie faced all kinds of weather. Elected a member of Parlia- 
ment, he did not see fit to change his mode of living. A 
singular point about Elwes was that he was perfectly willing 
to risk large sums of money in speculation. He gambled al- 
most ferociously, and on one occasion lost seven thousand 
pounds sterling at a game of piquet. He was scrupulously 
exact in all money matters, and was a man of his word in all 
things. His intellect was above the average. 

The will of a lady is now being contested in the courts of 
this State, of whom it has been shown that, although worth 
several millions of dollars, she denied herself the common 
necessaries of life, both as regarded food and clothing. 

Descuret ' cites a case that occurred in his own experience : 
During the severe winter of 1829-30 he was summoned by 
the commissary of police to visit an old beggar-woman who 
had been found dead in her bed. In a vast garret, dirty and 
otherwise repulsive, the corpse was found. The body was 
emaciated to an extreme degree, and was covered with ver- 
min. It was that of a woman of about sixty-five years of age. 
There were no signs of violence or of any bodily disease. 
Death was attributed to cold, for the icy wind had free access 
through the badly glazed windows. And more thorough ex- 
amination made this conjecture a certainty. There was no 
other bed-covering than a thin woollen blanket full of holes. 
The chimney was closed hermetically, and the fireplace, free 
from ashes, showed that there had been no fire since the be- 
ginning of the winter. Doubtless she had contemplated 
having a fire if the cold weather continued, for half of the 
garret was filled with wood piled up to the eaves. 

Several days afterward he learned through the public jour- 
nals that the Juge de paixh&d found more than ten thousand 
francs concealed in the mattress of this miserable woman. 

It would be easy to adduce other examples of avarice con- 
stituting, by its morbid development, as true a state of lunacy 
as is to be found in the annals of psychological medicine. 

Jealousy, when it exists to an abnormal extent, may also 
overcome the reasoning powers of the individual. Maillet 3 
admits this when he says that under the influence of this pas- 
sion there is produced such an outburst of grief that the 

1 Op. cit., t. ii, p. 293. 

2 "De Tessence des passions, 6tude psychologique et morale," Paris, 1877, p. 
398. 



EMOTIONAL MONOMANIA. 411 

mind is overthrown. Snch was the jealousy of Othello. 
Many crimes are committed through the influence of this pas- 
sion, and the plea of insanity is often set up in behalf of the 
offenders against the law. Some are probably insane, others 
have simply acted through heat of passion. The difference 
between these conditions will be pointed out when we come 
to the subject of diagnosis. It may, however, be said now 
that, to constitute insanity to such an extent as to render the 
individual irresponsible for his acts, it must be shown that 
the emotion had really become ungovernable, that he had en- 
deavored to subjugate it to his intellect and will, and that he 
was not merely yielding to a vicious propensity which he 
might have controlled. 

Among the emotional monomanias, nostalgia, or the mor- 
bid state of mind produced by the desire to return home, is 
worthy of some special consideration. It is more frequently 
met with among sailors and soldiers, who are more or less re- 
strained in the ability to return home, than among others. In- 
deed, the consciousness that the individual can do so if he 
chooses is of itself sufficient to prevent any development of 
the condition in question, while, on the other hand, the con- 
viction that he is separated from his home and friends, with- 
out the possibility of returning to them, is a powerful pre- 
disposing cause of the disorder. 

During the recent civil war I had the opportunity of ob- 
serving a great many cases of nostalgia. As a rule, they oc- 
curred in young soldiers who were drafted into service, but, 
owing to the facility with which after the development of se- 
vere symptoms sick furloughs were obtained, deaths from 
this cause were infrequent. I have, however, in my earlier 
military service, witnessed one case in which there was a fatal 
termination. 

Although there is ordinarily in an active campaign suffi- 
cient diversion for the mind of such a character as to prevent 
the soldier fixing his thoughts for any great length of time 
on home and its associations, yet when winter comes, or when 
from other causes it is impossible to continue active oper- 
ations, or when garrisoning posts, where but little variety 
marks the days as they drag slowly along, the mind of the 
soldier who has a home instinctively turns to the fireside he 
has left. Imagination pictures to him the events that are 
there occurring ; at night he dreams of them, awaking in the 



412 DESCRIPTION AND TREATMENT OF INSANITY. 

morning to pass another weary day in pining for the com- 
panionship of those he loves, and the scenes amid which he 
was born and has lived. The continuation of such emotions 
eventually produces a morbid condition of the mind, and 
with it marked disorder in the functional operations of the 
organism. The most prominent physical state is a general 
emaciation from want of appetite, and defect in the process 
of digestion and assimilation. Obstinate constipation alter- 
nates with exhausting attacks of diarrhoea, and sometimes a 
typhoid condition is induced, and the patient quickly suc- 
cumbs. 

At first, the mental phenomena are those of intense apathy. 
Nothing rouses the patient from the hebetude which exists, 
and which is apparent in every expression of his face and 
every word he utters. He cares for nothing. He only wishes 
to be left alone to indulge in the thoughts of home which are 
constantly passing through his mind. At a later stage there 
may be delirium, characterized by incoherence of speech, and 
muscular agitation and illusions and hallucinations are not 
uncommon. In these the scenes of his native farm or village, 
the appearance of friends, their voices, play a prominent part. 
Finally, gastro-intestinal symptoms become fixed, the deliri- 
um is more pronounced, the stupor more profound, and death 
closes the scene. 

It was in this way that I saw a young Alsacian, a recruit 
in the Second U. S. Dragoons, die, in the summer of 1849, on 
the plains between Fort Leavenworth and Santa Fe. 

But, even when the affection is in its last stage, the pros- 
pect of a return to his home will often cause the patient to 
rally. The promise of a furlough is, as Delasiauve J says, a 
touchstone before which the symptoms speedily vanish. 

On the other hand, the music of some familiar song aggra- 
vates the deplorable condition. So strong is the influence of 
music that it has often been found necessary to prohibit the 
regimental bands playing airs which could recall or freshen 
the memories of home. 

Some nations afford more examples of nostalgia than 
others. As a general rule, the more mountainous and wild the 
country, the more prone are the natives to nostalgia when re- 
moved from it. The Swiss, the Savoyards, the Laplanders, 
are peculiarly the subjects of this affection. The American 
1 " Nostalgie," Journal demedecine mentale, t. v, 1865, p. 238. 



EMOTIONAL MONOMANIA. 413 

Indian also readily dies of grief if separated from the scenes 
amid which he has lived. On the contrary, the negro is lit- 
tle liable to the affection, even when forcibly abducted from 
his home and sold into slavery. So far as my observa- 
tion extends, the Anglo-Saxon race exhibits little procliv- 
ity to nostalgia. The cause of this immunity is doubtless 
to be found in the fact that this race is, above all others, 
especially the American branch of it, the least attached to 
localities. 

Young persons are more subject to nostalgia than indi- 
viduals of mature age. In the army this is particularly the 
case, almost all the examples of it occurring in soldiers who 
have not reached their twenty-first year. 

The best means of preventing nostalgia is to provide occu- 
pation both for the mind and the body. Idleness is the great 
immediate cause, obviously for the reason that time and op- 
portunity are afforded for the indulgence of the imagination. 
Thus it is that the affection is apt to occur among the in- 
mates of hospitals, especially in those who are wounded and 
confined to their beds, though capable of fully exercising 
their minds. Soldiers placed in hospitals near their homes 
are always more liable to nostalgia than those who are in- 
mates of hospitals situated in the midst of or in the vicinity 
of the army to which they belong. In the one case the remi- 
niscences of home are more powerfully brought before the 
mind, while in the other the current of thought is more liable 
to run in another direction. Besides, being near one's home 
is always a stimulus to the hope of reaching it, which expec- 
tation not being realized, the nostalgic condition is developed, 
while, when it is certain that under no circumstances can a re- 
turn to one's fireside take place, the mind accepts the terms 
so imperatively imposed, and ceases to hope for what is im- 
possible of attainment. Baudens * very strongly insists upon 
the carrying out of this principle in the location of hospi- 
tals, and in the regulations which should prevail relative to 
sending men home when they are temporarily disabled. 
The recent civil war in this country likewise furnishes 
ample experience of the correctness of the views here laid 
down. 

That nostalgia is a form of insanity has been recognized 
from the earliest periods of the scientific study of the subject. 

1 "La guerre en Crimee," Paris, 1858, p. 36. 



414 DESCRIPTION AND TREATMENT OF INSANITY. 

Pinel 1 regarded it as a species of melancholia. Esquirol 9 
cites it as one of the causes of suicide, the Swiss and Scotch 
soldiers being especially prone to kill themselves under the 
influence of the despair which constitutes one of its most 
prominent symptoms. Delasiauve 9 considers it as evidently 
belonging to th,e order of partial moral manias. Benoist de la 
Grandieu 4 speaks of it as a neurosis of the brain, character- 
ized by the inability of the patient to overcome a depressing 
passion — remembrance. And Haspel, 6 while affirming that it 
is not insanity, says : 

" There is with nostalgics a distraction which is not usual, 
which may even lead to a certain incoherence of ideas, but 
which only in exceptional cases passes to such a degree as to 
constitute mental alienation. The intelligence, doubtless, is 
weakened, depressed, but not abolished ; there is a paucity of 
ideas and a feebleness in their production, and of words with 
which to give them expression, but they are always logical. 
The course of the ideas is slower than is natural, and their 
circle is narrowed, but that is all. The will is subjugated and 
in a condition of inertia and impotence, but the reason is not 
dethroned. There is a complete consciousness of exciting cir- 
cumstances ; and, though the subjects of nostalgia are tor- 
mented by ideas which are sad and strongly melancholic in 
character, they are yet not insane." 

It may certainly be said of this last expression of opinion 
that it is not justified by the immediately preceding statements. 

Rey, 8 in an elaborate article, expresses the opinion that 
nostalgia is a disease in which there is organic perturbation 
with corresponding functional trouble, due primarily to a psy- 
chic lesion of the passion of remembrance. I may anticipate 
here what I will have to say relative to the treatment of in- 
sanity in all its forms by stating that nostalgia is not an af- 
fection in which much is to be gained by the mere administra- 
tion of medicines. The emotion of hope, when once aroused, 
will do more than the whole dispensary in dispelling all symp- 

1 Li Nosographie philosophique," etc., 5ieme edition, Paris, 1813, t. iii, p. 97. 

2 " Des maladies mentales," Paris, 1838, t. i, p. 268. Op. et loc. cit., p. 232. 

3 Op. el loc. cit. 

* " De la nostalgie ou mal du pays," Paris, 1873. 

6 " De la nostalgie," " Memoires de l'academie de medecine," Paris, 1874. 
8 Art. " Nostalgie," in JS r oitveau dictionnaire de medecine et de chirurgie pra- 
tiques, t. xxiv, Paris, 1877. 



EMOTIONAL MONOMANIA. 415 

toms of the disease, and in some cases it may be necessary 
for the military surgeon to send the nostalgic soldier to his 
home in order to save his life. This, however, should be done 
with all possible precautions to prevent his comrades becom- 
ing acquainted with the fact. If it is impossible to separate 
him from the army, all means calculated to amuse, to inter- 
est, and to occupy the mind should be brought into requisi- 
tion. 

Anger, the love of gambling, ambition, and other emotions 
may likewise, through excess, become insanities, but there 
is nothing special to be said of them different from what has 
been brought forward in regard to love, pride, and vanity, 
avarice and jealousy. 

The emotion oifear in its relations to mental derangement 
requires, however, a more extended consideration, and to this 
division of the subject the attention of the reader is now 
invited. 

Passing over the subject of fear, in the presence of real or 
apparent danger, and which by its intensity may cause insan- 
ity or even death, we come to those morbid fears which are 
experienced by some persons without the existence of any 
external cause, but solely in consequence of a disordered 
state of the nervous system. They may be either general and 
ill-defined or special, being experienced in one direction only. 

Panophobia. — By panophobia is to be understood a form 
of mental derangement in which there is an imperfectly de- 
fined sense of fear ; an apprehension that something is about 
to happen to the detriment of the individual without any 
clear perception of the nature of the impending evil. 

Usually there are prodromatic symptoms, consisting both 
of mental and physical phenomena. The individual is rest- 
less, anxious, sleeps badly, has abnormal sensations, such as a 
feeling of constriction, weight, fulness, or pain in the head. 
There is often an uncomfortable feeling at the pit of the 
stomach, and something similar in the legs, constituting the 
condition known as anxietas tibiarum. These are not insiDired 
by illusions, hallucinations, or delusions, though these may 
all be developed in the course of the disease. 

The countenance of the patient expresses the state of the 
mind. The eyes glance wildly or furtively about the apart- 
ment, the senses seem to be on the alert and to be morbidly 
acute, and the movements are those of a person on the look- 



416 DESCRIPTION AND TREATMENT OF INSANITY. 

out for and fearful of an attack of some kind or other. The 
conversation is mostly on the subject that fills the mind of the 
individual. " I know something will happen to me," said a 
lady to me a few mornings since ; "it is useless to reassure me, 
for you do not feel what I feel. I cannot tell you what it 
will be, but something terrible is impending." Ere long the 
symptoms increase in intensity, but never in definiteness, and 
the subject weeps and wrings her hands over expectant 
troubles and dangers which she cannot explain. 

Cases oi this disorder are by no means rare. The citation 
of one or two of the most striking that have come under my 
observation will give a clearer idea of the phenomena than 
any abstract description : 

Mrs. K. consulted me November 10, 1880. She had been 
married seven years, but had never been pregnant. She was 
about twenty- seven years of age. For several weeks she had 
been unable to sleep more than two or three hours each night. 
Lying in bed awake was extremely unpleasant to her. She 
could not read, for the effort to do so made her head ache, so 
she generally passed the greater part of the night walking the 
floor or sitting at the window looking at the heavens or into 
the street. Toward morning she became completely ex- 
hausted, and then was able to sleep, as I have said, two or 
three hours. 

One cause of her wakefulness was the apprehension that 
something would happen to her in her sleep. The founda- 
tion of this fear she based upon the fact that during the past 
year her father and two aunts had met with serious acci- 
dents while asleep. Her father, nearly seventy years of age, 
had lost the use of his arm from having lain upon it all night, 
and thus producing paralysis. One aunt had died from cere- 
bral haemorrhage, and the other had fallen out of bed and 
broken her thigh. She herself had several times walked in 
her sleep. 

During nearly the whole period that she was awake she 
was in a constant state of apprehension lest something would 
occur to injure her. What it was that was going to happen 
she could not imagine, and, if questioned in regard to any 
probable event, always answered in the negative. I ran 
through the whole list of fire, murderous attacks, buildings 
falling on her, horses running away, mad bulls, hydrophobic 
dogs, poisoning, etc., to all of which she replied that she did 



EMOTIONAL MONOMANIA. 417 

not think it would be any of those things, but that something 
would happen. At times she got relief from her fears, but 
the least excitement would renew them in all their violence. 
Coming to visit me had excited the fear that I would do 
something to her, or that I would tell her something unfav- 
orable to her recovery, or that the excitement consequent 
on seeing a strange physician might prove injurious. Her 
friends said she had never been more specific in her decla- 
rations, but, when asked what I would do, or what I would 
tell her, or what the excitement would produce, she did not 
know. 

While in my consulting-room she walked up and down 
the floor, looking wildly about her, and gulping as if affected 
with the globus hystericus. When I asked her what she was 
afraid of, she wrung her hands together and said, " Oh, I do 
not know, I do not know ; but I am sure I will never get 
away safely ; something will happen to me, I am sure." Then 
she opened each door in turn, then looked out of the win- 
dows, and then began to sob and moan. 

In a few minutes she became more composed, but she 
would not go into my examination-room, and it was only 
after great persuasion that I succeeded in getting an ophthal- 
moscopic examination. I found double optic neuritis, though 
she had never complained of any failure of sight. 

I at once gave her two drachms of the bromide of sodium 
in a single dose, and directed that she should take for three 
days a drachm three times each day. At the end of that 
time she was very decidedly better, and, under the continued 
use of the bromide, in doses of fifteen grains three times a 
day, she was in less than a month entirely well. During that 
period the nape of the neck was cauterized with the white- 
hot platina disk four times, and her bowels were kept well 
open with aloetic purgatives. 

In the case of a lady whom I saw only a few days ago, the 
symptoms, though not of so long a duration, were even more 
intense at times, though she enjoyed periods of almost com- 
plete relief from the morbid apprehensions with which she 
was affected. Her physical symptoms were similar to those 
of the patient whose clinical history has just been given — that 
is, pain in the head, insomnia, restlessness, noises in the ears, 
etc. But, when the mental phenomena were at their height, 
her face and ears became very red, the temporal arteries were 

27 



41S DESCRIPTION AND TREATMENT OF INSANITY. 

enlarged and pulsated strongly, and the pupils were con- 
tracted to mere points. 

But she came to see me of her own accord, and was willing 
to do anything or to submit to any treatment, however harsh, 
if she could only be relieved of her terrible apprehensions. 
She sobbed and cried and wrung her hands, at the same time 
exclaiming that she ' ' knew nothing would happen. How 
could anything happen ? and yet I am afraid ! I am afraid ! 
Oh, what shall I do, what shall I do ? You will cure me, won't 
you ? " and so on at intervals during her visit of nearly an 
hour. 

She is still under treatment, but, from the good results 
thus far obtained, a favorable termination may, I think, be 
confidently expected. 

This patient was subject to hallucinations of sight and 
hearing, especially of the latter. Thus, she often heard voices 
telling her there was no hope for her, that she was about to 
die, and that she could shorten her anguish of mind by taking 
her life. 

In both these patients there was gastric dyspepsia and 
constipation, the former evidenced by enormous eructations 
of gas and a feeling of weight in the stomach, beginning 
shortly after eating, and lasting two or three hours. The 
food, in fact, underwent fermentation instead of digestion, as 
it does in other cases of nervous dyspepsia. 

But in neither, nor in others of similar character that have 
come under my observation, was there any derangement of 
the intellect when the mind could be brought to look calmly 
at the situation. The emotion of fear was, however, so in- 
tensely manifested that when it was at its height there was 
some intellectual confusion, and perhaps some delusions. 
These latter, however, had no permanency, and were of the 
most undefined character. A few words of reassurance and 
confidence sufficed to dissipate them. 

Dagonet ' states that patients suffering from the affection 
in question, which he describes under the name of "anxious 
lypemania" (lypemanie anxieuse), are very often tormented 
by suicidal impulses, which have no other motive than the 
desire to terminate for themselves an existence which for 
the crimes they have committed would otherwise end on the 

1 " Nouveau traite elementaire et pratique des maladies mentales," Paris, 1876, 
p. 241. 



EMOTIONAL MONOMANIA. 419 

scaffold. I have never seen this symptom in simple panopho- 
bia, nor can I believe that it exists in the affection unless it is 
complicated with delusions. On the contrary, the patients 
are afraid of death, and at times they are afraid, as they 
say, that they may become insane and commit suicide, but 
not even hallucinations of hearing of the most pointed char- 
acter have ever in my experience suggested the idea of self- 
destruction. Neither do I agree with him in the opinion that 
the prognosis of panophobia is bad. One of my cases, that of 
a young woman from New London, terminated in chronic mel- 
ancholia, but all the others, seven in number, made good re- 
coveries. It is very much more frequent in women than in 
men, according to my experience, and appears to be some- 
times connected with ovarian disorder. 

Undoubtedly panophobia may pass into insanity of a more 
pronounced form, and I have already given a case in which 
this result ensued, intellectual monomania with depression 
being the sequel. It is, however, equally certain that there 
are cases in which there is no tendency to a change of type. 

But, besides this condition of general and undefined fear, 
there are other affections in which the emotion is mani- 
fested in a special, determinate, and restricted way. One of 
the first of these, recognized and described as a distinct form 
of morbid fear, is the fear of being alone in a large place, or, 
as it was designated by Westphal, 1 who first systematically 
described it, agoraphobia. Gelineau, 2 with perhaps greater 
philological accuracy, calls it Jcenophobia, and Legrand du 
Saulle 3 describes it under the name of the fear of spaces. 
As all these terms imply, there is a morbid fear on the part 
of the individual to go into large places, or into the street, or 
the open country. 

But cases of the affection, without any special significance 
being attached to them, were observed long before Westphal 
published his paper on the subject. Thus it is stated of Pas- 
cal 4 that, in 1654, while driving on the Pont de Neuilly in a 
carriage with four or six horses, the leaders took the bits in 

1 " Archiv. fur Psychiatrie," Heft i, 1871. 

a "De la kenophobie ou peur des espaces (agoraphobie des allemands)," 
Paris, 1880. 

3 " Etude clinique sur la peur des espaces (agoraphobie des allemands)," 
Paris, 1878. 

4 " Preface aux ceuvres de Blaise Pascal," par Bossut, Paris, 1819, t. i, p. xxxii. 



420 DESCRIPTION AND TREATMENT OF INSANITY. 

their mouths and plunged so violently that, breaking the 
traces, they were precipitated into the Seine. The danger to 
the inmates was very great, but, happily, they escaped without 
other injury than a great fright. The incident, however, made 
so powerful an impression on Pascal that he ever afterward 
imagined that there was an abyss at his left side, or, rather, 
he knew there was not, but he had the morbid fear of falling 
into a large space. It was in vain that arguments were used 
with him ; he could not overcome the fear, and hence he kept 
a screen on the side at which he feared the chasm was situ- 
ated, so that he might by the device reassure his mind. 1 Gel- 
ineau 3 thinks that the great man was the subject of agora- 
phobia. 

Benedict reported a case of agoraphobia, but failed to re- 
gard it in its true light. He considered the phenomena as 
being due to visual troubles, overlooking altogether the cen- 
tric character of the affection. 

As soon as the subject of agoraphobia finds himself alone, 
for instance in the street, he is seized with the most intense 
fear. He cannot advance a step, he cannot go back ; he can 
only stand and tremble, with the perspiration starting from 
every pore, and terror depicted on every feature of his coun- 
tenance. His head seems to go round, the houses appear to 
be in motion, and he clutches for support at an area-railing, a 
lamp-post, the side of a house, or crouches in his fright on 
the pavement. As soon as some one comes to his relief and 
leads him into a house, his alarm disappears, and the physical 
manifestations of his fright also rapidly vanish. 

Mr. X., a Cuban gentleman, was sent to me by my friend, 
Dr. Desvernine, of Havana, to be treated for an affection from 
which he had suffered for several years, and which had baffled 
all means of treatment. I found that he would not go out 
into the street unless he went in a carriage, and that, in pass- 
ing from the vehicle to the door of a house, he required the 
support of two men — one on each side of him. In his apart- 
ments at the hotel he walked freely, and would go up and 
down stairs without difficulty. As soon, however, as he found 
himself out on the door-step his terror began. It seemed to 
him as if everything was in motion, and as though it would 
be impossible for him to live another minute unless assistance 

1 See, for a full discussion of the subject, " L'amulette de Pascal," par F. 
Lelut, Paris, 1846. a Op. cit, p. 4. 



EMOTIONAL MONOMANIA. 421 

were given Mm. At the same time, his brain appeared to be 
in motion within his sknll. A cold sweat broke out over his 
body, especially his forehead, his heart palpitated violently, 
his arms and legs trembled with the terror that inspired him, 
and every now and then a severe spasm wonld seize him, and 
his limbs wonld be strongly contracted and his body bent 
forward in the shape of a bow. At night his alarm was less 
strongly manifested, and he would walk out if some one took 
his arm. During the day, however, he could not be per- 
suaded to do more than to take the few steps necessary from 
a carriage to the door, and then an attendant had to take his 
arm. 

Under medical and moral treatment he improved so greatly 
that I succeeded in getting him to walk from his hotel to my 
residence daily, a friend walking by his side and a carriage 
following him closely. Then he walked several miles through 
the streets in the lower part of the city, a friend still by his 
side, and eventually he came to my house alone, but this last 
was a severe task for him. He repeated it, however, on several 
occasions, and, when he returned home at the end of about 
two months, he was almost entirely free from apprehension 
when out in the streets. 1 He was still, however, nervous, irri- 
table, and disposed to be hypochondriacal. 

In another case, that of a gentleman from Connecticut, 
sent to me by Dr. Hubbard, of Bridgeport, there were similar 
symptoms, although not manifested to the same extent. 
There was a like terror, a feeling of distention in the head, 
and more or less confusion of ideas if the attempt were made 
to go out of the house into the street. This patient is still 
under treatment, but at the end of a week there is very de- 
cided improvement. These are the only cases of agoraphobia 
that have come within the range of my personal experience. 

Although agoraphobia may exist as a primary disease, it 
undoubtedly often owes its origin to some previously existing 
morbid condition. Thus, it may be grafted upon the hysteri- 
cal state, upon dyspepsia, or gout. The vertiginous condition 
met with in certain epileptics, or patients suffering from cere- 

1 On the 12tli of September, 1882, about a month after this gentleman's ar- 
rival in New York, I operated on him in presence of Dr. Rubino, of Naples, and 
Dr. Cisneros and Dr. G. M. Hammond, of New York, for abscess of the liver, 
removing about seven ounces of pus from the organ. A perfect recovery fol- 
lowed, and to this date, January 19, 1883, there has been no return. 



422 DESCRIPTION AND TREATMENT OF INSANITY. 

bral syphilis, such as the case described by Webber,' and 
which Gelineau a mistakes for agoraphobia, is certainly not 
this affection. Indeed, Webber's case and it have very 
little in common. In one of my cases, the first, there was 
dyspepsia which had existed for several- years ; in the other, 
there had been excessive emotional disturbance in business 
matters. 

In neither of my patients was there any intellectual dis- 
turbance, nor were there illusions or hallucinations. They 
were capable of reasoning, with entire correctness, in regard to 
their unfortunate state. In both of them — and the same ap- 
pears to be true of all instances — if there was a certainty in 
their minds that, if anything happened to them, relief was 
at hand, they had little or no difficulty in going out. It was 
curious to observe how, in the case of the Cuban patient, as 
the condition became alleviated, less and less security was 
required. At first two attendants, one on each side, were 
necessary, then one holding his arm, then one walking along- 
side of him but not touching him, then a carriage at the dis- 
tance of a few feet behind him, and so on till he was able to 
walk in the street without reliance on external aid. Bourdin 3 
reports a case in which a man would risk himself on steep 
rocks and jump from one to the other with daring, provided 
there was below him a projection or a spot of ground on which 
he could fix his eyes. Without this his terror was such that 
he could not take a step. 

Cordes, 4 who himself suffered from agoraphobia, regards 
it as merely a symptom of certain depressed states of the 
nervous system. It begins, according to his personal experi- 
ence, in a simple fear of some unknown danger, which goes 
on increasing in intensity, and which is accompanied with 
palpitations, precordial anxiety, flashes of heat, tinnitus, 
vertigo, heaviness, and numbness of the extremities — all work- 
ing upon him at once and producing the most unsurmounta- 
ble terror. He assimilates it to the vertigo a stomacho lseso 
of Trousseau, from which, however, it is very different. 

Regarding it as being due to a hyperaemic condition of the 
brain, I have treated my cases with the bromides of sodium 
and ergot, and the moral agent of insisting on the patient at- 

1 Boston Medical and Surgical Journal. 2 Op. cit., p. 26. 

3 "Del'horreur du vide," Paris, 1878. 

* " Archiv fur Psychiatrie und Nervenkrankheiten," 1872, Heft iii. 



EMOTIONAL MONOMANIA. 423 

tempting to rely on himself in open places. Arthius reports 
two cases cured by statical electricity, and this means seemed 
to be of service in the one case in which I employed it, as did 
also cups repeatedly applied to the nucha. 

The name claustrophobia has been given, by Br. Verga, of 
Milan, to a morbid fear the very opposite in its characteris- 
tics to that just described. It consists, as the name implies, of 
a terror of closed places, the phenomena in other respects 
not being essentially different from those of agoraphobia. 
Cases similar to those given by Yerga have been reported by 
Dr. Raggi, of Bologna ; by Meschede, at the Congress of Ger- 
man Naturalists and Physicians, held at Cassel in 1878 ; and 
by Professor Ball, 1 of Paris. A single case has come under 
my own observation. 

In one of Professor Ball's two cases, the patient, a married 
lady, whose father had been insane, and who was the mother 
of three children, two of whom were imbecile and one epilep- 
tic, had been in good physical and mental health till an at- 
tack of typhoid fever deranged both her mind and body. 
She had attacks of cerebral congestion, was affected with ex- 
treme sadness, and had thoughts of suicide. One day she 
went with some friends to visit the tower of Saint Jacques, 
and, while making the ascent, was suddenly seized with terror. 
The idea occurred to her that some one had shut the door be- 
low, and that she would not be able to get out. She could 
not go up another step, notwithstanding the assurances of 
those who were with her, and descended as rapidly as she 
could to the ground, overcome with fright. As soon as she was 
out in the open air, the feeling of alarm disappeared. From 
this time on she had similar feelings whenever she was alone 
in a closed room. Nothing, she said, would induce her to re- 
main in such a place. If the attempt be made, she is seized 
with vertigo, her head becomes confused, her terrors reap- 
pear, and she no longer knows what she does. The opening 
of the doors and windows gives relief. 

Professor Ball concludes that there is a special form of de- 
lirium characterized by the fear of closed places, and that it 
is a true psychosis and not a mere sensorial trouble. 

In the single case which has occurred in my own experi- 
ence, the patient, a gentleman engaged in manufacturing 

1 "De la claustrophobie," "Annales m6dico-psycliologiques," November, 
1879, p. 378. 



124: DESCRIPTION AND TREATMENT OF INSANITY. 

cotton goods, had suffered for several weeks with the symp- 
toms of cerebral hyperemia, the principal of which was in- 
somnia. The cause was probably to be found in excessive 
anxiety due to business troubles. 

He first experienced the phenomena of claustrophobia 
while ascending in a hotel elevator to his room on the fifth 
floor. A sudden terror seized upon him ; he clung to the man 
who had charge of the apparatus, his head swam, a whistling 
noise was heard in his ears, and a cold prespiration broke out 
over his body. As soon as he stepped out into the hall above, 
the symptoms disappeared. He went to his room, feeling a 
slight degree of nausea, but, on entering the apartment, the 
feelings reappeared, though with less intensity. He opened 
the windows and the door, and then felt more at ease. Since 
then he has been unable to enter any small apartment without 
experiencing similar feelings, unless there are other persons 
present, and even then at times, his terror gets the better of 
him. A railway car is especially alarming, and the small ones 
used on the street railways he cannot enter at all. He stands 
on the platform in all weathers. Even the idea of entering a 
carriage excites apprehension unless it is an open one, and 
then he can travel in it with ease. Nothing, however, would 
induce him to get into a close vehicle, such as an omnibus or 
stage. There is no intellectual aberration with this gentle- 
man. He does not believe anything is going to happen ; he 
simply fears that some indescribable occurrence will take 
place, and this fear excites such an ungovernable terror that 
he becomes powerless to move or even to speak. 

The foregoing extract from my note-book is dated October 
29, 1879. I attached no particular significance to the special 
phenomena of the condition till I read Professor Ball's paper 
on the subject. Since that date I have seen the patient sev- 
eral times. I treated him in a manner similar to that I had 
used in the cases of agoraphobia, with equally good results. 
He has remained free from the affection. 

Dr. Beard 1 has described several kinds of these morbid 
fears, all of which have a marked resemblance to each other, 
differing only in the cause. Thus, there is an astraplio- 
bia, or the fear of lightning ; an anthropophobia, or the fear 
of society ; and a monophobia, or the fear of being alone. 

1 " A Practical Treatise on Nervous Exhaustion," etc., New York, 1880, p. 
27, et seq. 



EMOTIONAL MONOMANIA. 425 

Of these two latter, several instances have come under my 
notice. 

One species, which appears to me to be more characteristic 
than any other, and of which several examples have occurred 
in my own experience and in that of other physicians, I pro- 
pose to consider at some length. This is mysopJiobia (Mvo-os, 
defilement, pollution, contamination, and </>o/3o?, fear), the 
fear of pollution, and was described by me in a paper read 
before the New York Neurological Society, April 7, 1879. * 

In all, fourteen cases up to the present time constitute the 
basis of my experience. Of the first seven cases my notes are 
not very complete. I was not particularly impressed with the 
fact of the distinctive character of the affection, although in 
all I find it stated that the subjects had morbid fears in regard 
to pollution. Of the other cases, I select the following as ex- 
hibiting the features of the disorder : 

M. Gr., a lady, thirty years of age, and a widow for three 
years, consulted me February 20, 1877, for what was consid- 
ered to be incipient insanity, and an affection in all proba- 
bility requiring, it was feared, incarceration in a lunatic asy- 
lum. The patient was quiet and orderly in her demeanor, 
and, so far as her friends' accounts went, entirely sane except 
upon the one point of fear of contamination, which was ex- 
hibited by mental distress and the practice of repeatedly 
washing her hands without there being obvious cause for so 
doing. She was perfectly coherent in regard to her clinical 
history, and I obtained from her the following account of the 
origin and progress of the disease, which I transcribe in her 
own language : 

"I was, about six months ago, reading a newspaper one 
evening, when I came across an account of a man who, it was 
believed, had contracted small-pox from handling bank-notes 
which had been a short time previously in the possession of a 
person suffering from that disease. The circumstance made 
a deep impression on my mind, and, as I had only a few 
moments before counted quite a number of notes, the idea 
struck me that perhaps they had been handled by some per- 
son with a contagious disease of some kind or other. I had 
washed my hands just after counting these notes, but, think- 
ing that I had not possibly removed all the taint, I washed 
them again. I went to bed, feeling quite uncomfortable, and 

1 "Misophobia," Neurological Contributions, No. 1, 1879. 



426 DESCRIPTION AND TREATMENT OF INSANITY. 

the next morning paid more than nsual attention to the wash- 
ing of my hands. I then recollected that I had placed the 
notes in a drawer of my dressing-table, in contact with linen 
which I had proposed putting on that day. I changed my 
intention, however, and selected some from another drawer 
instead, sending the other to the laundry. I then put on a 
pair of gloves, took out the notes, placed them in a letter-en- 
velope, and had the drawer thoroughly washed with soap and 
water. 

"Keflection upon the matter brought to mind the fact 
that, after counting the notes, I had touched various things 
before washing my hands. I could not recall what these 
things were, and hence I was made very uncomfortable, for 
the idea occurred to me that I must have touched some of 
these things after washing my hands, and that, therefore, I 
was still in danger. The very dress that I wore then, was the 
same that I had on now, and my hands had been more less in 
contact with it all the morning. I felt myself, accordingly, 
forced to wash my hands, to take off the dress, and again to 
wash my hands. 

" From that I went on from one thing to another. There 
was no end to the series. I washed everything I was in the 
habit of touching, and then washed my hands. Even the 
water was a medium for pollution, for, no matter how thor- 
oughly I wiped my hands after washing in it, a portion still 
remained, and this had to be washed off, and then again the 
hands washed. There was no end to it. The soap became 
connected in my mind with contamination, and I never used 
the same piece twice. 

" Now, I can touch nothing without feeling irresistibly im- 
pelled to wash my hands afterward. If I am prevented doing 
so, I experience the most horrible sense of fear. I am always 
looking at my hands to ascertain if I can see anything on 
them, and I have a lens which I use to aid my eyesight. I 
have no particular apprehension of contracting small-pox or 
any other disease that I can specify. It is an overpowering 
feeling that I shall be defiled in some mysterious way, that 
presses on me with a force that I cannot resist. As to shaking 
hands with any person, nothing would persuade me to do so 
unless I had on gloves at the time. 

" And, lately, even gloves do not seem to afford me entire 
protection. I know they are porous, and that, therefore, the 



EMOTIONAL MONOMANIA. 427 

subtle influence, whatever it may be, is capable of passing 
through them to my hands." 

On my asking this lady if she really believed in the theory 
she had constructed, she answered that at times she was con- 
vinced that she was in error, but only for a short period, as 
the original ideas returned in full force ; that, when reasoned 
with in regard to the absurdity of her notions, she was per- 
suaded for the moment that she was wrong, but as soon 
as she was left to herself she was back in the old train of 
thought. 

The expression of the patient was one of anxiety. As she 
sat talking to me she was continually rubbing her hands to- 
gether, and looking at them closely every moment. After I 
had felt her pulse, she took a handkerchief from her pocket, 
moistened it with a little cologne-water which she had in a 
phial, and wiped the spot which my fingers had touched. 

To test the sensibility of the hands, I made use of the 
sesthesiometer, without, however, detecting any abnormal con- 
dition ; but she at once took another handkerchief and wiped 
all the places touched, with cologne, as before. She had a 
pocket full of clean handkerchiefs, never using the same one 
twice, and putting the soiled ones in another pocket. 

She had given up reading, because handling books or 
newspapers was, she was sure, a certain source of contami- 
nation. At first this idea was only applied to books from a 
library to which she was a subscriber, but latterly it had been 
extended to all printed matter. 

Further examination showed that she was subject to al- 
most continual headache, mainly at the vertex, and that she 
had occasional attacks of dizziness. She slept badly, fre- 
quently getting only one or two hours of disturbed slumber. 
Her pulse was 96, weak and irregular. The heart-sounds were 
normal, but the action of the heart was feeble, with an irregu- 
lar rhythm and an occasional intermittence. The ophthalmo- 
scope showed nothing abnormal beyond a possible slight in- 
crease in the red tiDge of the disk. 

Menstruation was regular in every respect, but there was 
decided gastric dyspepsia. The phosphates of the urine were 
in great excess ; in other respects there was no derangement of 
this excretion. No hereditary tendency to insanity or other 
neurotic condition existed. Previous to the occurrence of the 
mental disorder in question, she had been of equable tempera- 



428 DESCRIPTION AND TREATMENT OF INSANITY. 

ment, and not at all disposed to melancholy or depression of 
spirits. Now, however, her mind was filled with the most 
gloomy forebodings and apprehensions. Her life was one 
continued state of fear lest she had become contaminated by 
something she had touched, and had forgotten to wash her 
hands after the contact, or had imperfectly washed them. 

So far as could be discovered, there was no existing source 
of trouble or anxiety. She was in affluent circumstances, and 
had lived happily with her husband, who had, however, died, 
a year after marriage, of phthisis, with which he had been af- 
fected for several years. There had been no pregnancy. 

Another case was that of a young lady, aged eighteen, tall 
and slender, whom I first saw January 23, 1879. From her- 
self and her mother I obtained the following history : 

About eighteen months previously she had gone to stay in 
the country with some friends, and on one occasion slept in a 
farm-house. On her return home she at once took a bath, and 
had her head, the hair of which was very long and thick, 
thoroughly washed ; to her great surprise and disgust it was 
found to be full of lice. She had always been exceedingly 
cleanly as regarded her person, and the shock she experienced 
on learning of the presence of these parasites completely un- 
nerved her. She insisted on repeated washings of the head 
with soap, carbolic acid, and other detergent and disinfectant 
substances, and even then was not convinced that all the ver- 
min had been destroyed. 

This was the starting-point of all the subsequent mental 
disturbance. Little by little the idea became rooted that she 
could not escape sources of contamination, that other persons 
might defile her in some way or other, and that the various 
articles about her might also possess a like power. She was 
particularly careful in regard to avoiding children, and would 
not on any account allow a child to touch or even to approach 
her closely. When she went out into the street she carefully 
gathered her skirts together on passing any person, for fear 
that she might by mere contact be contaminated. She spent 
hours every day in minutely examining and cleansing her 
combs and brushes, and was even then not satisfied that they 
were thoroughly purified. 

As to her hands, she washed them, as her mother informed 
me she had ascertained by actual count, over two hundred 
times a day. She could touch nothing without feeling irre- 



EMOTIONAL MONOMANIA. 429 

sistibly impelled to scrub them with, soap and water. Gradu- 
ally the idea of lice had been lost sight of, and for several 
months previously to her coming to me the fear of pollution 
had had a much more extended source. She could not define 
with any exactness what the mater ies pollutionis was, though 
she imagined it to be something that was capable of doing her 
bodily injury in some subtle manner by being absorbed into 
her system through her hands or other parts. 

Some little time before coming under my observation she 
had extended her fear of contamination to the soap with 
which she felt compelled to wash her hands, and then she 
was obliged to wash them again in pure water in order to re- 
move all traces of the soap. Then, as the towel with which 
she wiped them dry had been washed with soap, she rinsed 
her hands in water, and allowed them to dry without the aid 
of a towel. 

In removing her clothes at night preparatory to going to 
bed, she carefully avoided touching them with her hands, be- 
cause then she would not have sufficient opportunity for 
washing. She, therefore, had some one else to loosen the fast- 
enings, and then she allowed her garments to drop on the 
floor, where she left them. Nothing would have persuaded 
her to touch any of her under- clothing after it had been worn 
till it had been washed. A great source of anxiety with her 
was the fact that her clothes were washed in the laundry with 
the clothing of other people ; but she saw no practicable way 
of escape from this circumstance. It nevertheless made her 
very unhappy. 

When not washing her hands or examining her combs and 
brushes, she spent nearly all the rest of the day in carefully 
inspecting every article of furniture and dusting it many 
times. 

Thus, her whole life is one continued round of trouble, 
anxiety, and fear. Her whole character and disposition have 
changed. She is suspicious of every person and of every 
thing. 

She is subject to insomnia, frequent headaches, and loss 
of appetite. There are noises in her ears and flashes of light 
before the eyes, and an utter impossibility of concentrating 
the attention upon any other subject than the one which has 
obtained so complete a mastery over her. Her menstruation is 
scanty and somewhat painful, though regular in other respects. 



430 DESCRIPTION AND TREATMENT OF INSANITY. 

Ophthalmoscopic examination showed the retinal vessels 
to be increased in size, and the choroids to be of a deeper hne 
than is ordinarily met with. 

In conversing with this yonng lady, . I had no difficulty in 
getting her to admit the absurdity of her ideas. She stated 
that whenever she reflected upon the subject she was convinced 
of their erroneous character, but that, nevertheless, she could 
not avoid acting as she did ; for, as soon as she was exposed 
to any possible source of contamination, the ideas returned in 
full force. It was only when she had, as she thought, done 
her best to cleanse her hands that she doubted the correctness 
of her notions, which had so thoroughly become a part of her 
mentality. 

These cases are sufficient to show the nature and charac- 
teristics of general mysophobia. Interesting cases of the af- 
fection have since been described by Seguin, 1 Russell, 2 and 
Shaw, 3 and I have heard of others of which I have not been 
able to obtain full particulars. 

But there is another form of the disease — two examples of 
which have recently come under my notice — and this is a fear 
of contamination from some one particular source. In one of 
the instances the patient, a distinguished mining engineer, 
had a morbid fear that he would be polluted in some inexpli- 
cable way if he sat down on chairs or benches used by other 
people unless there was a metallic plate between his body and 
the seat. He, therefore, carried about with him a copper 
plate about twelve inches in diameter and covered with black 
cloth. Whenever he sat down he interposed this plate, and 
thus considered that he had secured his safety. He was par- 
ticularly apprehensive in regard to the cushioned seats of 
railway -cars, carriages, omnibuses, churches, theatres, etc. A 
plain wooden chair did not cause him so very much terror, 
but the idea of the others excited the most uncomfortable 
sensations, both mental and physical — similar in general feat- 
ures to those experienced by the subjects of agoraphobia or 
claustrophobia. 

In the other case, which was that of a lady of this city, 
there was a combination of a morbid fear and an impulse to 
expose herself to the action of the source of the fear. Thus, 

1 " A Case of Mysophobia," Archives of Medicine, August, 1880, p. 102. 

2 " Mysophobia," etc., Alienist and Neurologist, October, 1880, p. 529. 



8 U 



A Case of Mysophobia," Archives of Medicine, October, 1881, p. 199. 



EMOTIONAL MONOMANIA. 431 

she had read in the newspapers that persons had contracted 
diseases in some way or other from moistening postage-stamps 
with the tongue, and the fear soon afterward was excited in 
her that she might become affected with some horrible disease 
by like means. Notwithstanding the terror with which she 
was inspired, she felt impelled to expose herself to the danger 
she feared, and conld with difficulty refrain from licking not 
only the stamps she used, but those employed by other mem- 
bers of her family. She was hence in a continual state of 
mental inquietude from the action of two kinds of emotional 
disturbance, and suffered the greatest agony in consequence. 
Not being always able to restrain herself, she would ask any 
one she saw about to close a letter to allow her to affix the 
stamp, and having performed the act, would be seized with 
the most overpowering fear of the consequences of what she 
had done, during which she would weep and wring her hands, 
and utter the most poignant expressions of the anguish she 
was suffering. It finally became impossible to keep postage- 
stamps in the family ; but she would buy them and stick them 
on envelopes, and then experience a repetition of her terror 
at the thought that she had again rendered herse]f liable to 
disease. I saw this patient several times, but, before much 
progress was made toward her relief, she was summoned to 
Europe by the sudden illness of her husband, and I lost sight 
of her. 

Dr. Willis P. King, 1 of Sedalia, Missouri, has described an 
interesting case of pyrophobia, or the fear of fire, occurring 
in a ten years' old boy. Among other symptoms of the con- 
dition in question, it is stated that he went repeatedly during 
the day from room to room and inspected the stoves and the 
flues about the house. He went to bed at night protesting 
against the building of fires, and in the morning, when the 
cook began the preparations for breakfast, at the first noise of 
poker or shovel he would bound out of bed, not taking time 
to put on his trousers, and would hurry down to the kitchen 
to prevent the fire being made. He had to be watched by his 
mother during the preparation of the meal, and, as soon as 
the work was done, the fire had to be extinguished to allay 
his fears. He would deliberately extinguish the fire in the 
sitting-room against his mother's orders. On one occasion, 

1 " Case of Morbid Juvenile Pyrophobia," etc., Alienist and Neurologist, 
July, 1880, p. 345. 



432 DESCRIPTION AND TREATMENT OF INSANITY. 

when the morning was cool, he succeeded, after a contest 
with his mother, in opening the stove-door and pouring a 
bucket of water over the fire. These contests were of daily 
occurrence. On all other subjects but that of fire he conversed 
rationally and intelligently. He was cured by quinine, the 
bromides, and the use of evaporating applications — ether — to 
the head. 

These special morbid fears are not unlike those which some 
persons acquire relative to certain diseases. Thus, there is a 
syphilopliobia, or the fear of syphilis ; a hydropTiobophobia, or 
the fear of hydrophobia ; a spermatophobia, or the fear of sper- 
matorrhoea, etc., many cases of which have come under my 
notice, and which are, doubtless, familiar to most physicians 
in large cities. The subjects of all these conditions struggle 
energetically against their fears, but they are rarely successful 
in overcoming them by their own unaided efforts. Though 
the intellect is scarcely if at all involved, they are, nevertheless, 
as truly insane for the time being as the most raving maniac, 
though, of course, to a less extent. Indeed, there are few 
more miserable beings in the world than he who fears that he 
is affected with spermatorrhoea, and few who show more ter- 
ror than the subjects of hydrophobophobia. They generally 
yield promptly to proper medical, moral, and hygienic treat- 
ment. 

b — EMOTIONAL MORBID IMPULSES. 

Emotional morbid impulses differ from intellectual mor- 
bid impulses in that they have an emotion as their factor 
instead of an idea. They constitute a large and important 
part of that form of mental derangement described several 
years ago by Dr. Prichard under the name of moral insanity, 
but which have been designated by certain government experts 
in a recent notable criminal trial under the general head of 
" wickedness." In thus defining them, the experts in ques- 
tion placed themselves on record against the opinions of those 
alienists in this country and in Europe who are most com- 
petent to form a scientific opinion on a question of psycho- 
logical medicine. Indeed, the number of alienists who do not 
believe in the existence of emotional morbid impulses as a 
form of insanity is not much greater than the number of ex- 
perts for the prosecution in the trial in question. 

Among these impulses is that which prompts to theft — 
kleptomania, as it is generally called. It is not so much from 



EMOTIONAL MOKBID IMPULSES. 433 

an exaggeration of the emotion of cupidity that kleptomaniacs 
exist as it is from the pure love of stealing. It is the act of 
taking what does not belong to them which is generally the 
source of the pleasure derived, and not the acquirement of the 
things stolen, which often are of no use, and are cast aside as 
soon as obtained and their very existence forgotten. As an 
instance in point, I cite from a recent communication 1 the 
particulars of an interesting case which occurred in my own 
experience : 

" A young man, a student of law, suffered from an attack 
of scarlet fever. During the stage of convalescence, as he was 
one day sitting at the window looking out on the street, his 
attention was attracted by two men, each of whom wore a 
very large watch-chain. They passed on, and he thought 
nothing more of the circumstance till that night, when he 
awoke suddenly from a sound sleep with the idea that he 
must have those chains. He tried to dismiss the matter from 
his mind, but in vain. Do what he would, it constantly re- 
curred to him ; so he got up and sat down to think of the 
strange desire with which he had so suddenly become pos- 
sessed. Two or three hours were passed in this way, and then, 
it being daylight, he dressed himself and went out to walk, 
hoping that exercise in the morning air would rid him of his 
infatuation. But the effect was very different from what he 
had anticipated, and, before he returned home, he had made 
up his mind that no pleasure in this life would be comparable 
to that he would derive from having the two watch-chains in 
his possession. 

"He was in good circumstances, a graduate of a well- 
known college, and in all the relations of life had borne him- 
self creditably ; moreover, he had a very fine watch and chain 
which had been given him by his father. 

" Five or six days elapsed, during which time the desire to 
obtain the watch-chains was the most prominent emotion of 
his mind. Hour after hour was passed in forming plans to 
get them into his possession, but there seemed to be no way 
by which his wish could be gratified. He watched from his 
window, he walked the streets, looking all around him, in the 
hope of seeing the men. He even went to several large jew- 
elry establishments and inspected the watch-chains, with the 

1 "A Problem for Sociologists," Forth American Review, November, 1882, 
p. 424. 

28 



43± DESCRIPTION AND TREATMENT OF INSANITY. 

object of ascertaining if there were others like those on which 
his mind was set. He visited a large theatre and carefully 
scrutinized the audience, but all was to no purpose. Finally, 
one afternoon, as he was returning home from the office in 
which he was a student, he suddenly came face to face with 
one of the men he had previously observed. A glance was 
sufficient to show him that the watch-chain was still in its 
place. He at once turned and followed the man several 
blocks, till he observed him enter a jeweller's shop. He went 
in also. The man was talking to a salesman, and the watch 
and chain lay on a counter between them. The object of his 
desire was now within his reach. He stood by as if waiting 
his turn to be served, trembling with excitement and joy, his 
eyes riveted on the chain. He determined not to leave the 
shop without getting the chain into his possession by some 
means or other. Suddenly he felt that the time had come, 
and, without a moment's hesitation, he seized the watch and 
chain and dashed out of the door. The street was crowded, 
and twilight was just beginning. The cry of " Stop, thief ! " 
was at once raised, and he was hotly pursued ; but, after run- 
ning a short distance, he contrived to mingle with the crowd, 
and, retracing his steps quietly, actually had the boldness to 
pass the jeweller's shop again. He reached his house safely, 
exhausted with the excitement he had undergone, but happy 
in the consciousness of having successfully accomplished half 
his self-appointed task. 

u The gratification he experienced encouraged him to per- 
severe in his efforts to get the other chain, and he continued 
on the lookout for the man who wore it. In the mean time he 
contemplated his acquisition with mingled feelings of pleasure 
and disgust. He had done more than he had intended, for 
he had no desire for the watch which he had stolen along with 
the chain. On the contrary, it was a source of great discom- 
fort to him. Besides, although he was intensely gratified at 
possessing the chain, he could not disguise from himself the 
fact that he was a thief, and eligible to imprisonment for the 
crime of grand larceny. It was necessary to his peace of 
mind to return the watch, so he inclosed it in a box and sent 
it, with many precautions for insuring his own safety, to the 
jeweller from whose shop he had taken it, with the request 
that it might be returned to the owner. As to the chain, not 
valuing it for any use it might be to him, he wrapped it in a 



EMOTIONAL MORBID IMPULSES. 435 

piece of India-rubber cloth and buried it in a hole which he 
dug for the purpose in the cellar. But after a time, from 
frequently analyzing his feelings, he perceived that the pos- 
session of the chain gave him no pleasure ; it was the act of 
taking it which was the source of the satisfaction he had ex- 
perienced. He therefore dug it up, and sent it, also, back to 
the jeweller. He never saw either of the two men again, and 
gradually the desire to possess or obtain the other chain faded 
out of his mind. 

" But about a year afterward he was attacked with wake- 
fulness, which proved to be of the most intractable kind, and 
with pain in the head, vertigo, noises in the ears, hallucinations 
of hearing, and other symptoms of a disordered brain. He then 
came under my observation, and, in the course of the examina- 
tion to which he was subjected, told the story which has just 
been related. He also stated that he remembered very dis- 
tinctly that, when the dream to obtain the watch-chains first 
occurred to him, he had experienced a severe attack of vertigo, 
and almost fell from the chair on which he was sitting. He 
was not quite sure that he did not for an instant lose con- 
sciousness. On inquiry being made of the jeweller to whom 
he said he had returned the watch and chain, it was ascer- 
tained that the account he had given of the robbery and the 
restoration was entirely correct." 

In another case, the patient, a young lady, who had been 
very carefully brought up, and who had for several years been 
an inmate of a large school, without having committed the 
slightest act against good morals, was suddenly seized with 
the desire to possess herself of all the small things belonging 
to others upon which she could lay her hands. Jewelry, 
gloves, handkerchiefs, fans, books, and even money, were 
taken from shops and private houses which she visited. No 
use was made of the articles. They were all, money included, 
thrown into a large drawer in an old piece of furniture which 
stood in an unused room. Finally she was detected, and a 
scandal was with great difficulty prevented. All the articles 
were discovered and returned quietly to their respective own- 
ers, and one or two importunate and impracticable tradesmen 
were silenced by considerable sums of money. Her father, 
believing his daughter's mind to be deranged, brought her to 
me, and no lengthened examination was necessary to convince 
me that she was the subject of brain disease. I found that 



436 DESCRIPTION AND TREATMENT OF INSANITY. 

she was sleepless, that she had repeated attacks of vertigo 
daily, that she had pain in her head, and at times more or 
less mental confusion. She spoke freely of the pilfering pro- 
pensity to which she was subject, and of the great mental 
distress which it caused her. It was not from any desire to 
possess the articles stolen which induced her to take them, 
but an overpowering love for the act of stealing. The things, 
when once she had them in her possession, lost all inter- 
est for her, and she would willingly have restored them but 
for the shame attendant on the discovery that would have re- 
sulted, and the fear of the consequences. She knew perfectly 
well that it was both a sin and a crime to steal, and was per- 
fectly aware of the consequences should she be detected. The 
desire, however, to appropriate to herself articles which came 
in her way was, as she said, absolutely irresistible. At least 
it could not be resisted without causing an amount of mental 
suffering the very idea of which filled her with horror. Once 
or twice she had for a time refrained from secreting things 
which she handled in shops she had visited ; but the anguish 
she had endured was such that she had been forced to return, 
and, on pretext of wishing to examine something else, to hide 
the articles in question in her muff or under her cloak. Then 
she felt comfortable, and, carrying them home, tossed them 
into the drawer without even looking at them. 

While she was describing her condition, and was sobbing 
with unsuppressed emotion, I saw her quietly take a book 
from the table near which she sat. She did not look at it, 
but very stealthily put it under a sealskin jacket she was 
wearing. I said nothing at the time, but before she left the 
room I remarked to her, " If you are thinking of studying 
medicine, I would recommend you to begin with a book in the 
English language and of a more elementary character than 
the one you have under your jacket." She took it from its 
hiding-place at once and replaced it on the table. " You see 
how it is with me," she said ; "I was obliged to take the 
book." It was a volume of Wernicke's "Lehrbuch der G-e- 
hirnkrankheiten," not a word of which could she have read. 
A few days afterward I received by mail a bulky package, 
which, on opening, I found to contain a pair of my gloves, 
which, notwithstanding my vigilance, she had succeeded in 
abstracting from under my very eyes, and which she now re- 
turned, with the expression of her contrition. 



EMOTIONAL MORBID IMPULSES. 437 

I may anticipate here and say that, under the use of 
nuchal cauterization and the bromide of sodium, this lady 
entirely lost her impulse in about six weeks, and that she has 
remained well to this time — some six or seven months after- 
ward. 

Sometimes the impulse to steal does not extend beyond a 
single class of objects, and it may, as in the instance of the 
young man whose case I have given, be limited to one article, 
dying out when that article is acquired. 

A few years ago a young man was arrested in this city for 
assaulting a young lady in the street. He was identified as a 
person who had committed many previous offences of a like 
character. His plan was to rush up to a young lady, seize 
her, throw her down, and take off her shoes, which he car- 
ried away with him. He did not attempt otherwise to injure 
her, or to take away any other article from her. On search- 
ing his trunks and drawers, they were found full of women's 
shoes. He said he had no use for them, and was actuated by 
an irresistible impulse which it was pleasant for him to 
gratify. 

In another case, in regard to which I was consulted, the 
patient, a young man, eighteen years of age, had a desire, 
which he declared he could not resist, to steal books of what- 
ever kind came within his reach. With him it was the love 
for the objects themselves that prompted him to theft. There 
was in this instance, as perhaps there is to some extent in all 
analogous cases, a decided weakness of the intellect. The 
love for books rarely prompted him to read any one of his 
acquisitions — which were many and valuable. He told his 
mother, a widow, that a gentleman had taken a great fancy 
to him, and gave him books in order that his mind might be 
improved by reading them. Finally, one night he attacked, 
in the streets of the town in which he lived, a smaller boy, 
who was carrying a package of books to the house of a pur- 
chaser. He knocked the boy down, and, taking the parcel, 
made off with it. He was arrested, however, and then all his 
misdeeds in the way of thieving from booksellers, libraries, 
and acquaintances were exposed. Although there was suffi- 
cient evidence to show not only the boy's insanity, but the 
hereditary character of his disorder, he was sent to the House 
of Correction, where he now is. 

Kleptomaniacs can sometimes be diverted from their love 



43S DESCRIPTION AND TREATMENT OF INSANITY. 

of stealing by turning their attention to some other way of 
satisfying their cupidity. Thus, I once overcame in a wealthy 
lady a strong desire to steal whatever she could lay her hand 
on, by turning her attention to the subject of botany, and 
inducing her to make collections of plants. She gradually 
became so infatuated with her new pursuit that she lost all 
kleptomaniacal symptoms. 

In another case, that of a gentleman who could not resist 
the gratification he experienced at stealing silver spoons or 
forks from the dinner-tables at which he was a guest, I 
pointed out the interest attached to the corks of wine-bottles, 
and suggested that, if some one would make a collection of 
the different kinds, it would be curious and suggestive. He 
at once took up the idea, and began to take bottle-corks in- 
stead of forks and spoons. Of course, no one cared how many 
corks he took, and he could gratify his acquisitive propensity 
without danger to his reputation. He has an interesting col- 
lection of corks, classified according to the wines for which 
they have been used, and arranged with system and taste. 
He allows no one to see it, but he has willed it, so he tells 
me, to a prominent art museum. 

Another variety of emotional monomania is the love of 
setting fire to houses and other things, and which is desig- 
nated pyromania. This is an abnormal manifestation of the 
love of destroying, with which most persons are born, and 
which is often shown at a very early age. Many instances of 
this kind of mental disturbance are on record, and there is no 
doubt that it exists as a distinct type of morbid emotional 
disorder. It appears to be decidedly more common with 
women and girls than with males. 

" A lady came under my observation who was subject to 
no delusion, and who had never exhibited any evidence of 
mental alienation except in showing an impulse, which she 
declared she could not control, to throw valuable articles into 
the fire. At first, as she said in her confession to me, the im- 
pulse was excited by the satisfaction she derived from seeing 
an old pair of slippers curl up into fantastic shapes after she 
had thrown them into a blazing wood fire. She repeated the 
act the following day, but, not having a pair of old shoes to 
burn, she used instead a felt hat which was no longer fashion- 
able. But this did not undergo contortions like the shoes, 
and, therefore, she had no pleasurable sensations like those of 



EMOTIONAL MORBID IMPULSES. 439 

the day before, and thus, so far as any satisfaction was con- 
cerned, the experiment was a failure. On the ensuing day, 
however, she felt, to her great surprise, that it would be a 
pleasant thing to burn something. She was very clear that 
this pleasure consisted solely in the fulfilment of an impulse 
which, to a great extent, had become habitual. She, there- 
fore, seized a handsomely bound prayer-book which lay on 
the table, and, throwing it into the fire, turned away her face 
and walked to another part of the room. It was very certain, 
therefore, that she was no longer gratified by the sight of the 
burning articles. She went on repeating these acts with her 
own things, and even with those which did not belong to her, 
until she became a nuisance to herself and to all those with 
whom she had any relations. Her destructive propensities 
stopped at nothing which was capable of being consumed. 
Books, bonnets, shawls, laces, handkerchiefs, and even table- 
cloths and bed-linen, helped to swell the list of her sacrifices. 
As soon as she had thrown the articles into the fire the im- 
pulse was satisfied. She did not care to see them burn ; on 
the contrary, the sight was rather disagreeable to her than 
otherwise. But the power which affected her in the way it 
did she represented as being imperative, and, if not imme- 
diately allowed to act, giving rise to the most irritable and 
painful sensations, which she could not describe otherwise 
than by saying that she felt as if she should have to fly, or 
jump, or run, and that there was a feeling under the skin 
all over the body as though the flesh were in motion. As 
soon as she had yielded to the impulse these sensations dis- 
appeared. She was eventually cured by being placed under 
restraint and subjected to medical treatment." 1 

This patient was subject to attacks of migraine, during 
which her head throbbed violently, and the vessels of the face 
were greatly injected. She also suffered from insomnia and 
vertigo, especially at her menstrual periods. 

Esquirol a cites from Henke the case of a servant-girl who, 
returning from a dance at which she had become over-heated, 
was seized with an incendiary impulse. For three days she 
experienced anxious and otherwise uncomfortable feelings, 
and then she set fire to a building. She declared that when 

1 " A Problem for Sociologists," North American Review, November, 1882, 
p. 430. 

2 "Des maladies mentales," Paris, 1838, t. i, p. 374. 



440 DESCRIPTION AND TREATMENT OF INSANITY. 

she saw the fire she experienced a greater degree of pleasure 
than she had ever felt before. 

A wheelwright's apprentice, a countryman, eighteen years 
of age, made sixteen incendiary attempts in the space of four 
months. He always carried with him a sponge coated with 
sulphur. Although to satisfy his appetites he had often been 
guilty of theft, and though he was poor, he never stole any- 
thing from the houses he destroyed. He was not actuated by 
any other feeling than the pleasure of seeing the fire he 
kindled, and in hearing the bells ring, the lamentations of 
those who suffered the loss of their property, the noises in 
the street, etc. ' 

Marc, 3 in calling attention to the fact that pyromania is 
often met with in young persons, cites the following cases 
among others from Henke : 

A girl, less than fifteen years of age, affected with nos- 
talgia, twice set fire to the house in which she lived. She 
declared that from the first moment of entering her master's 
service she had been seized with the desire of destroying his 
house by fire. It seemed to her that a ghost standing before 
her constantly urged her on to the act. This girl had for a 
long time suffered from pain in the head and disordered men- 
struation. 

Another, aged twenty- two years, committed incendiarism 
four times. She said she was tormented by a nervous feeling 
which forced her to set houses on fire. 

A third, servant of a farmer, twice set fire to the house. 
She said she had never had any trouble with her master or 
mistress, but that she was actuated by an impulse arising 
from a voice within her, which urged her to burn the house 
and then to hang herself. On the first occasion she looked 
with calmness and pleasure at the fire she had kindled ; the 
second time she gave the alarm, and then tried to hang her- 
self. No signs of intellectual derangement could be discov- 
ered, but her physical health was bad. 

Livi, 3 in an exhaustive study of the subject, expresses the 
opinion that incendiarism is not only committed as a conse- 
quence of illusions and hallucinations, mania or lypemania, 

1 Esquirol, Op. cit., loc. cit. 

2 4 ' Considerations medico-16gales sur la monomanie et particulierement sur 
la monomanie incendiaire," Annales cPhygi&ne publique et de medecin legale, t. 
x, 1833, p. 435. *Archivio Italiano, February, 1867. 



EMOTIONAL MOKBID IMPULSES. Ml 

and intellectual monomania, but through the influence of in- 
stinctive monomania, which is only another name for the emo- 
tional monomania under consideration. With Henke, Marc, 
and others, he thinks that the function of menstruation makes 
pyromania more frequent in the female than in the male sex. 

Flechner, 1 on the other hand, contends that these factors are 
without special influence in producing any form of pyromania, 
but he admits, by inference, at least, that it may be due to a 
special morbid impulse which forces the subject to destroy by 
fire. 

Another form of the destructive propensity is seen in the 
emotional form of liomicidal mania. In this variety of men- 
tal derangement there is an intense desire to kill, and the 
development of pleasurable feelings, as the result of yielding 
to the longing. Murders are, therefore, perpetrated by the sub- 
jects of this variety of emotional monomania, which are with- 
out malice, or cupidity, or any other emotion, save that of 
the gratification of their passion for killing. And they often 
resist, with every evidence of sincerity, the morbid impulse 
with which they are actuated. Occasionally the desire to 
kill a human being may be diverted by turning the attention 
to the idea of gratifying the emotion by killing the lower ani- 
mals. Thus, George t 2 relates, on the authority of Werbe, the 
following particulars of a case in point : 

"At midnight a man presented himself at the country- 
seat of the celebrated Antoine Petit, and begged him to cure 
him of an invincible propensity to kill his master, whom he 
had served for fifteen years. He added that he had also a 
strong desire to kill himself. The idea had come to him very 
suddenly, and he could not overcome it. Petit received the 
man kindly, made him sit down, quieted his agitation, and 
gave him a glass of good wine. At early dawn, under the 
pretext of getting some remedies for him, he took him to 
Paris, and, conducting him to a slaughter-house, made him 
cut the throats of several sheep. The man showed great de- 
light at the proceeding, but at the seventh victim he suddenly 
turned pale, and fell fainting to the ground. This man as- 
sumed the trade of a butcher, and, on the first day of every 
year, came to thank Petit for having saved him from the 
scaffold." 

1 " Psychiatrisches Centralblatt," 1874. 

2 " Discussion niedico-legale sur la folie," etc., Paris, 1826, p. 68. 



442 DESCRIPTION AND TREATMENT OF INSANITY. 

A hard-working gardener, residing in this city, came to 
consult me for relief from a longing which he experienced to 
kill his niece, who kept house for him. The desire had gradu- 
ally grown upon him, and he was fearful that he would not 
long be able to resist. It had first occurred to him one morn- 
ing at breakfast, when he had suddenly experienced the feel- 
ing that it would be a gratification to him if he could transfix 
her neck with a pitchfork. He rose in some agitation from 
the table, and went into his garden. He looked over all his 
pitchforks, and selected one with three prongs, which he 
thought would be the best one to use in case he should in- 
dulge his desire. However, he came to the conclusion that it 
would be a horrid thing to do, and an act for which he ought to 
be hanged without mercy. But every day as he met his niece 
at breakfast, the desire appeared, and was evidently growing 
upon him. One morning he placed his hands around her 
neck and said to her, in a playful way, that it would be "a 
good neck to stick a pitchfork through." Still, he had no 
serious idea that he would ever yield. He was much attached 
to his niece, and she to him, and they had always lived to- 
gether harmoniously. However, the desire grew on him, and 
finally became so strong that he began to feel that, after all, 
he would eventually be obliged to perpetrate the deed. Fi- 
nally the idea occurred to him that he would make an image 
which he would conceive for the moment to be his niece, and 
that he would plunge his pitchfork through its neck. He 
purchased a papier mache bust, and, attaching it to a trunk 
made of bagging stuffed with straw, stuck it up in his hot- 
house. The next morning, when the impulse came over him, 
he took his pitchfork and drove it through the neck of the 
counterfeit niece, with the effect of at once satisfying his de- 
sire. Every day thereafter, for a month or longer, he went 
through this performance, but gradually it lost its power, and 
he again began to feel that he would have to indulge his im- 
pulse to transfix his niece. One morning he went so far as to 
bring the pitchfork into the room and lay it on the floor by 
his side, so as to be ready for use, but by great effort he was 
enabled to restrain himself. The same day he consulted me, 
and gave me the foregoing particulars. I found that he was 
suffering from wakefulness, pain in the head, vertigo, noises 
in the ears, flashes of light before the eyes, and almost con- 
stant twitching of the facial muscles. Besides these symp- 



EMOTIONAL MORBID IMPULSES. 443 

toms of cerebral hyperemia, there was obstinate constipation 
of the bowels and dyspepsia. I gave him a prescription con- 
taining bromide of sodium, and directed the application of a 
dozen cups to the nape of the neck. Kecognizing, however, 
the fact that the niece was in considerable danger, I sent the 
uncle to the extreme lower part of the city to get his prescrip- 
tion, and to have the cups applied, and in the mean time sent 
word to the niece to come at once to my consulting-room. I 
knew that the uncle could not get back to his house under a 
couple of hours, and within that time I hoped to have the girl 
out of the city. She came at once, and, on learning of the 
danger to which she had been subjected, decided to go imme- 
diately to her mother, who lived in Canada. Before the uncle 
got home she was out of his house, and that evening left 
the city. I told him what I had done, and he expressed great 
gratification that I had probably saved him from committing 
a murder. With the disappearance of the niece the desire 
faded out, and, under the influence of the medical treatment, 
his cerebral disorder also disappeared. Four years have now 
passed, and, though he thinks he is entirely cured of his de- 
sire, he has not yet succeeded in persuading his niece to re- 
turn. Indeed, I have advised her not to do so, as there is no 
predicting with any degree of assurance that his impulse 
would not return. 

Dr. Carpenter ' quotes from the Report of the Morningside 
Lunatic Asylum for 1850 a case which is so apposite, as show- 
ing some of the chief phenomena of homicidal mania of the 
emotional form, that I quote it in full : 

" The case was that of a female who was not affected with 
any disorder of her intellectual powers, and who labored 
under no delusions or hallucinations, but who was tormented 
by a simple abstract desire to kill, or rather, for it took a spe- 
cific form, to strangle. She made repeated attempts to effect 
her purpose, attacking all and sundry, even her own nieces 
and other relatives ; indeed, it seemed to be a matter of in- 
difference to her wliom she strangled, so that she succeeded in 
killing some one. She recovered, under strict discipline, so 
much self-control as to be permitted to work in the washing- 
house and laundry, but she still continued to assert that she 
'must do it,' that she 6 was certain she would do it some day,' 
that she could not help it ; • surely no one had ever suffered as 

1 "Principles of Mental Philosophy," etc., London, 1874, p. 664. 



4M DESCRIPTION AND TREATMENT OF INSANITY. 

she had done ' ; was not her's ' an awfnl case ? ' And, approach- 
ing any one, she wonld gently bring her hand near their 
throat and say, mildly and persuasively, ' I would just like 
to do it.' She frequently expressed a wish that all the men 
and women in the world had only one neck, that she might 
strangle it. Yet this female had kind and amiable disposi- 
tions, was beloved by her fellow-patients — so much so that 
one of them insisted on sleeping with her, although she 
herself declared that she was afraid she would not be able to 
resist the impulse to get up during the night and strangle 
her. She had been a very pious woman, exemplary in her 
conduct, very fond of attending prayer-meetings and of visit- 
ing the sick, praying with them and reading the Scriptures, 
or repeating to them the sermons she had heard. It was the 
second attack of insanity. During the former she had at- 
tempted suicide. The disease was hereditary, and it may be 
believed that she was strongly predisposed to morbid im- 
pulses of this character when it was stated that her mother 
and sister had committed suicide. There could be no doubt 
as to the sincerity of her morbid desires. She was brought 
to the institution under very severe restraint, and the parties 
who brought her were under great alarm upon the restraint 
being removed. After its removal she made repeated and 
very determined attacks upon the other patients, the attend- 
ants, and the officers of the asylum, and was only brought to 
exercise sufficient self-control by a system of rigid discipline. 
This female was perfectly aware that her impulses were 
wrong, and that, if she had committed any crime of violence 
under their influence, she would have been exposed to pun- 
ishment. She deplored in piteous terms the horrible propen- 
sity under which she labored. 

" In the report of the same institution for 1853, it is men- 
tioned that this female had been readmitted after nearly suc- 
ceeding in strangling her sister's child under the prompting 
of her homicidal impulse. ' She displays no delusion or per- 
version of ideas, but is urged on by an abstract and uncon- 
trollable impulse to do what she knows to be wrong, and 
deeply deplores.'" 

In the year 1881, a woman came to my clinique at the Uni- 
versity of New York to be treated for, as she said, an insane 
desire to kill her two children, a boy and girl, aged, respec- 
tively, six and eight years. The desire had first occurred to 



EMOTIONAL MORBID IMPULSES. 445 

her at night, about a month previously, as she lay in bed try- 
ing to get to sleep. She felt as though she must do it. She 
accordingly rose from the bed, lit a candle, and went to the 
room where the two children lay. They were sound asleep. 
As she looked on them, the desire grew upon her, and in- 
creased to such an extent that she seized a pillow, and was 
about to smother the boy when her legs gave way beneath 
her, a cold sweat broke out over her whole body, and her 
arms became so weak that the pillow dropped from her hands, 
and she fell to the floor in an almost unconscious state. As 
soon as she was able, she hurried back to her own bed, terrified 
and weeping at the thought of the deed she had so nearly 
committed. She did not sleep all night, and the next morn- 
ing got up with a splitting headache and with a feeling as 
though her brain were on fire. 

Her husband, who had been absent, returned that day, 
but she was afraid to mention her temptation of the night 
before, lest he might summon a physician, and she should be 
thought insane and placed in a lunatic asylum. 

Besides, the desire to kill the children was beginning to re- 
appear, and she felt that she would have to yield in order to 
satisfy the longing which existed. She did not wish to be in- 
terfered with, and she resolved to make the attempt as soon as 
the children came home from school, and while her husband, 
who was a railway engineer, was absent. But when the boy 
and his sister entered the room they rushed up to her with 
some flowers a florist had given them, and that, she said, en- 
tirely changed the current of her thoughts and desires. She 
clasped them in her arms, kissed them, and hurried them out 
of her sight. From that time on the desire, though con- 
stantly present, was kept in subjection by the emotion of 
maternal love ; but, fearful that it might again get the ascend- 
ency, she had come for medical treatment. 

I found that she did not sleep well, sometimes passing the 
whole night without closing her eyes ; that she had a constant 
rumbling sound in her ears, and at times a loud and abrupt 
noise in the head like that produced by the discharge of a 
pistol ; that there was a dull, heavy pain in the top of the 
head, and a sensation as though an "animal of some kind 
was gnawing the scalp." Frequently during the day first 
one ear and then the other would burn till it became painful, 
and then all the head symptoms were increased in violence. 



446 DESCRIPTION AND TREATMENT OF INSANITY. 

Her bowels were obstinately constipated, and her menstrua- 
tion was generally retarded several days. 

I could detect no intellectual disorder ; neither were there 
illusions or hallucinations. She appeared to be of a calm and 
equable temperament, and she conversed in the most rational 
manner in regard to the terrible passion for killing her own 
children with which she was afflicted. She said that she felt 
it was becoming stronger every day, and that, unless some- 
thing were done for her, she should end by murdering them. 
She had not yet told her husband anything of the subject. 
I directed her to send the children at once to their grand- 
mother — and it was done before she left the room — and to 
send her husband to me as soon as he returned to this city. 
I saw him the next morning, and it may well be believed that 
his surprise and horror were intense when he heard what I 
had to tell him about his wife. He was a very sensible man, 
however, and, through his aid and that of the medical treat- 
ment to which she was subjected, she was in a few weeks 
entirely cured of her insane desire. As soon as she began to 
get sound and refreshing sleep, the impulse became feeble, 
and finally disappeared altogether. 

Closely allied to emotional homicidal impulse is that form 
of mental derangement which consists of an emotional im- 
pulse to the perpetration of suicide. It not infrequently hap- 
pens that the two conditions coexist in the same person. 
Dagonet ' cites the following case from Georget : 

The wife of a coppersmith came to me, says Georget, to 
request my advice for a state of mind which drove her to de- 
spair. She was apparently in good health, slept well, had a 
good appetite, and her menstruation was regular. She had no 
pain, and the circulation presented no evidences of derange- 
ment. But the woman complained of having at times ideas 
of killing her four children, notwithstanding that, as she said, 
she loved them better than she did herself. At these periods 
she felt afraid that she would do them some fatal injury, and 
she at the same time experienced a desire to throw herself out 
of the window. When these impulses were on her she be- 
came red in the face, and she was seized with a general trem- 

1 " Des impulsions dans la folie et de la folie impulsive," Paris, 1870, p. 65. 
Dagonet refers this case to Georget's " Discussion medico-legale sur la folie," 
etc., p. 21. No such case is, however, reported on that page, nor, so far as I 
can discover, on any other page of the monograph in question. 



EMOTIONAL MOEBID IMPULSES. 447 

bling of the whole body. She had no wish to injure other 
children, and when the impulse affected her she took care to 
keep out of the way of her children, and to hide all the knives 
and other sharp instruments in the house. There was no other 
mental lesion. This state had lasted about a month. The 
impulse in this woman was not very strong. Had it been, 
says Georget, a little more intense, she would have committed 
several horrible crimes. 

In some cases of emotional morbid impulse to suicide, the 
contemplation of the act is attended with feelings of pleasure. 
A man kills himself because he wishes to do so, and because 
of the satisfaction to be derived from gratifying his impulse. 
There is no abhorrence of the deed, no contest with himself in 
which he is overpowered. His intellect is not necessarily de- 
ranged ; he acts with the full knowledge of what he is doing ; 
and, if the circumstances require it, he employs the most sys- 
tematic and recondite stratagems in order to accomplish his 
purpose. He is neither governed by delusions nor by logical 
reasons. He is simply actuated by a passion which it is 
pleasant for him to gratify. When, however, the impulse has 
passed without having been realized, as is sometimes the case 
from accident or some more powerful influence, he looks back 
upon it with horror, and, shuddering at the escape he has 
made, perhaps seeks medical advice for what he feels is a dis- 
ease likely ere long to prove fatal. 

Thus, a lady, who had obtained a divorce from her hus- 
band on the ground of adultery, and who during the trial had 
suffered greatly both in mental and physical health, consulted 
me in regard to her condition. I found that she was entirely 
free from hallucinations, illusions, or any intellectual disorder, 
but that at times she was affected by an impulse to kill her- 
self with poison. At the first appearance of this disturbance 
she had no poison in her possession, and when it had passed 
off she had, of course, no wish to obtain the means ; but the 
second occasion occurred while she was walking in the street, 
and she at once entered a pharmacy near by and asked for 
two grains of strychnine, for the purpose, as she said, of kill- 
ing rats. As she had no prescription, the pharmacist declined 
to let her have the drug, so she was obliged to go without it. 
In a few minutes the impulse disappeared. 

These attacks alarmed her, especially as the second was 
much stronger than the first; so she resolved to consult a 



448 DESCRIPTION AND TREATMENT OF INSANITY. 

physician. But, before she did so, she was visited by the im- 
pulse for the third time, and this was far stronger than either 
of the others. It appeared to her that no act that she could 
commit would afford so much real satisfaction as that of tak- 
ing her own life. There was no reason why she should desire 
to do so except this. Her affairs were in good order, she was 
possessed of ample means, and the sympathy of the public 
had been with her in her dispute with her husband. She 
felt, however, as though it was impossible to resist the desire 
which was on her. She must do it. But she had no satisfac- 
tory means at her command. 

She reflected that, if she cut her throat or killed herself in 
any violent way, the fact would be known by the appearance 
of her dead body, and she shrank from the idea of the dis- 
grace which would attach to her in consequence. She would, 
she thought, get the poison, take it, and then go to bed to 
enjoy the idea that she had at last gratified the impulse ; she 
would almost imperceptibly pass into a stupor, and, when 
found dead in her bed next morning, every one would think 
that she had died of heart disease. To give additional color 
to this belief would be the fact that she had consulted several 
physicians, all of whom had told her that she had disease of 
the heart. It was then about eleven o'clock in the morning. 
She went out, and, purchasing a phial of McMunn's elixir of 
opium, returned, and, putting it to her lips, took the whole of 
it — about two ounces. She then lay down and began to think. 

But the result was quite different from what she had an- 
ticipated. At first she experienced the most intense gratifica- 
tion at the success of her plan. Nothing, she said, had ever 
given her such unalloyed pleasure as the thought that she 
had obeyed the impulse to self-destruction. But this feeling 
lasted only for a few minutes. The impulse suddenly disap- 
peared, and with its flight came a realization of the awful 
deed she had perpetrated. She sprang from the bed, and, 
though scarcely able to stand and with her mind already half 
stupefied by the opium, staggered into her sister's room, ad- 
joining her own, and told what she had done. While in the 
act of speaking she was fortunately seized with a violent fit 
of vomiting, as the result of the excessively large dose she 
had taken, and her life was thus saved. 

For several days she was confined to her bed, and then 
again the impulse to self-destruction returned. It was just 



EMOTIONAL MOKBID IMPULSES. 449 

subsequent to this fourth recurrence — which was slight, and 
which, as her friends were now aware of her tendency, she had 
no opportunity of gratifying — that she came under my obser- 
vation. She conversed with entire calmness and lucidity rela- 
tive to her desire to commit suicide, and which she now re- 
garded with aversion and terror. She was regular in her men- 
strual functions, had no pain in her head, slept well, and was 
apparently in good health, except that at the times when her 
impulse came she had a feeling of heat in the right side of 
her face, her ear burned and was red, and a humming noise 
was heard on that side. These, however, were phenomena in- 
dicative of vaso-motor paralysis, which often exist in conjunc- 
tion with the most perfect mental and physical health. I 
directed that she should be watched night and day, and I 
treated her with the bromide of sodium and ergot, with the 
effect of preventing any further return of her suicidal impulse. 

Marc ' states that he himself, in his youth, experienced a 
periodical impulse to commit suicide, which was clearly emo- 
tional in its character. Enjoying perfect health, he was at- 
tacked, for three years, every autumn with a feeling of anxiety, 
accompanied with an indefinable desire to take his own life, 
so that he was obliged to request one of his friends to watch 
him during the accession of the paroxysm, which, after lasting 
several days, ended with a nasal hemorrhage. There was no 
other evidence of cerebral congestion, his complexion being 
rather pale and sallow than high-colored. The only considera- 
tion which antagonized the desire for suicide was the thought 
of the grief into which his family would be plunged. 

Bertrand 2 cites the case of a man, in good circumstances, 
free from any source of anxiety or grief, and of apparently 
sound intellect, who was harassed by the desire to cut his 
throat whenever he shaved himself. He felt as though no 
pleasure in life would be comparable to that which he would 
derive from committing suicide in this way. 

At other times there is a terrible contest in the mind of 
the individual. Various emotions contend for the mastery, 
and the intellect may combat the desire for self-destruction 
which exists. Sometimes the will is overcome, and at others 
it resists all arguments and all other emotions, and the at- 
tempt is made. 

lu De la folie considered dans ses rapports avec les questions medico -judici- 
aires," Paris, 1840, t. ii, p. 162. 2 "Traite du suicide," Paris, 1857, p. 265. 

29 



450 DESCRIPTION AND TREATMENT OF INSANITY. 

Schnopp ' reports the following interesting case : 

F. de Z., an officer, twenty-seven years of age, at the 
termination of an attack of rhenmatic fever became timid 
and taciturn, but remained perfectly reasonable and lucid in 
his speech and writing. One evening he asked his servant for 
a pair of pistols, but, as the man refused to give them to him, 
he requested him to throw him out of the window. This also 
being refused, he, with no better success, asked for a sharp 
knife, adding that he wished to kill himself. He slept well 
that night, but the next morning made the same request of 
the cook, and then inquired if the court-yard under his win- 
dow was paved or not. Left alone for a moment, he threw 
himself out of the second-story window. By good luck the 
fall did not result seriously. Interrogated as to his reasons 
for so insane an act, he owned that for some time he had been 
possessed with the wish to kill himself — a wish of which he 
could not get rid. Neither his religious principles nor his 
reason, nor the sense of the shame that would attach to his 
family, could conquer the impulse, and that his tears and his 
prayers to God had been equally ineffectual. He was cured 
by travel and other hygienic means. 

It is by no means always the case that the emotional mor- 
bid impulse to commit suicide is permanently abolished after 
an attempt has been made. Thus, Brierre de Boismont 2 re- 
fers to the cases of individuals, one of whom had made several 
ineffectual efforts to asphyxiate himself, and who always kept 
a vessel full of charcoal in his room, so as to be in readiness 
for his next attempt ; and another constantly carried a rope 
about with him. A woman set fire to her furniture in order 
to destroy herself, first having tried to throw her child out of 
the window. Prevented in both attempts, she repeated them, 
still unsuccessfully. Finally, one morning, she strangled her- 
self. A man had the fortitude to make two attempts to kill 
himself by swallowing nitric acid ; next he cut his throat with 
a razor, but did not succeed in inflicting a mortal wound. The 
fourth attempt resulted according to his wish. He kindled 
several charcoal furnaces in his room, and died, asphyxiated. 

Another man started out to throw himself into the river, 
but was prevented by two persons, who followed him, suspect- 

1 " Paradoxie des Willens," cited by Dagonet, op. cit., p. 66, and Annates 
medico -psychologiques, juillet et septembre, 1870. 

2 "Du suicide et de la folie suicide," Paris, 1856, p. 442, et seq. 



EMOTIOXAL MORBID IMPULSES. 451 

ing his purpose. A second time he mounted the parapet of a 
bridge, in order to jump from it into the water, but was pre- 
vented by a sentinel calling to him. He then gave up the 
idea of drowning himself, and made preparations for throw- 
ing himself from the window, but was stopped by the unex- 
pected entrance of his brother into the room. Finally he 
succeeded with charcoal. 

In a former chapter I have referred to a striking case in 
which the attempt at suicide was repeatedly made, and finally 
with success. In another instance recently under my observa- 
tion, the impulse was renewed periodically as many as nine 
times, and three separate attempts to carry it out were made. 
In this case, as in the others cited in this connection, there 
were no delusions, but at each recurrence of the emotional dis- 
turbance there were hallucinations of hearing, apparently, 
however, without any relation, so far as their character was 
concerned with the impulse, to self-destruction. The patient, 
twenty-eight years old, was the wife of a physician in a neigh- 
boring State, and had suffered from repeated attacks of inter- 
mittent fever. She had been sleeping badly for several nights, 
and had been greatly troubled with frightful dreams. One 
night she woke with the sound of musical instruments in her 
ears, and with a desire to kill herself with a pair of scissors 
which she knew lay on a table in an adjoining room. With- 
out disturbing her husband, who was sleeping by her side, 
she got up, lit a candle, and went to get the scissors. She rec- 
ollected distinctly that while going to this room she had heard 
voices singing the words of a popular song of the day to an 
accompaniment of musical instruments. She recognized the 
fact that this was a hallucination, but the thought struck her 
that she would die to sweet music — a desire she had always 
expressed when the subject of death was discussed in her 
presence. She found the scissors, and, opening them, said 
aloud : ' ' Now I am going to be happy, " and instantly plunged 
the sharp blade into her left breast. The point entered just 
above the nipple, penetrating the mammary gland, but not 
entering the chest. Before she could repeat the blow, her 
husband, who had been awakened by her exclamation, en- 
tered the room and disarmed her. The wound was of no 
great consequence ; her embonpoint had saved her life. 

Instead of consulting another physician, the matter was 
kept quiet, especially as it was thought by those about her 



452 DESCRIPTION AND TREATMENT OF INSANITY. 

that she had been excited by a large dose of quinine she had 
taken that afternoon. The impulse had disappeared, and 
she expressed the utmost gratification at the failure of her 
attempt. But exactly two weeks subsequently, while engaged 
in sewing one afternoon, she experienced a renewal of the 
impulse. Again she felt that nothing could give her so much 
pleasure as the act of suicide, but, instead of a pair of scissors, 
a penknife was indicated as the weapon. Again she heard 
delightful music. She immediately opened a small penknife 
which she had in her work-basket, and, rolling up the sleeve 
of her dress, gave herself a deep gash across the bend of 
the elbow. She watched the blood flow in a stream from 
her arm, experiencing all the time the most intense satisfac- 
tion at what she had done. She thought she had lost about 
a quart, when she became insensible, and knew nothing more 
till she found herself in bed and her husband standing by 
her side. She made a good recovery, though she was very 
feeble, and for over a month was confined to her room. Of 
course, great care was taken to prevent any further attempts 
of the kind, and, as she passed over several periods of four- 
teen days without any recurrence of the impulse, it was hoped 
it would not again make its appearance. In this, however, 
there was disappointment, for on the seventeenth day from the 
second attempt the desire to kill herself returned. This 
time, however, she was not alone, and she was prevented 
sticking a two-pronged steel fork into her chest. The acces- 
sion of this impulse was, like the others, attended with the 
hallucination of music. After this she had, at intervals of 
fourteen days, five other recurrences of the impulse to kill 
herself, but, as she was closely watched at the expected times, 
she was unable to effect her purpose. Each was marked by 
the existence of a pleasurable feeling, and by hallucinations of 
music. She felt as though she could with an effort overcome 
the impulse, and she often reasoned in regard to it before 
making an attempt upon her life. The emotion of pleasure, 
however, which she felt would reach its height with the per- 
petration of the act, swept everything before it. The desire 
became so intense that no influence but that of main force 
sufficed to prevent her accomplishing her purpose. As she 
said to her husband one day : "If God Almighty and all his 
angels were to beg me to refrain, I could not do it." In the 
intervals she thanked those who had interposed for their good 



EMOTIONAL MORBID IMPULSES. 453 

offices in having saved her life, but always reminded them 
that she knew she, would make the attempt again, and that 
they must be on the watch. The impulse lasted not more 
than fifteen minutes. During its existence she struggled to 
escape from those who held her, or from the bands which con- 
fined her hands. 

The ninth attempt was partially successful, owing to the 
fact that when the desire appeared she dissembled by pre- 
tending that she was sure it was not going to come this time, 
and sending her sister out of the room to get a glass of cider 
for her. As soon as she was alone she rushed to the window 
and endeavored to open it, so that she might throw herself out. 
It was nailed fast, and she could not raise it. She looked has- 
tily around the room in search of means for her purpose, but 
could find nothing suitable. It was but the work of a mo- 
ment for her to hurry to the dining-room, and seizing a large 
carving-knife, to draw it across her throat. Fortunately it 
was dull, and she was obliged to make several attempts before 
she succeeded in inflicting a wound of any importance. As 
it was, before she could fully accomplish her purpose she was 
seized. She had made half a dozen cuts in her neck, one of 
which only had been deep enough to cause haemorrhage. 
This had cut the external jugular vein on the left side. A 
week subsequently she was brought to me, and gave me the 
foregoing particulars. I recognized the fact that she had 
periodical attacks of cerebral congestion, and, while I ad- 
vised the use of arsenic and the bromide of sodium, I insisted 
that the treatment should be carried out in a place of greater 
security than her own house. I recommended that she should 
be placed under the care of Dr. R. L. Parsons, at Sing Sing. 
Her husband promised to follow my advice in every particu- 
lar. He declared, however, that he must first take his wife 
home in order to make proper arrangements for her departure. 
On her way back, however, to the town in which she lived, 
she took a violent cold. Pleuro-pneumonia ensued, and she 
died within ten days thereafter. 

Drs. McLean and Brown report two cases of women who 
exhibited strong impulses to suicide without the implication 
of the intellect. Indeed, with the exception of slight ner- 
vous irritability, and the impulses in question, both subjects 
were in a state of the most complete mental health. They 
were good-tempered, of remarkable intelligence, and declared 



454 DESCRIPTION AND TREATMENT OF INSANITY. 

that they were perfectly happy, but they were overpowered 
with a violent desire to die. One of these was a yonng girl, 
cheerful, amiable, and as happy as could be. She had tried 
repeatedly to poison herself with laudanum, then to strangle 
herself, and then to open a vein with a darning-needle. Fi- 
nally she refused food, and had to be nourished by means 
of a stomach-pump. 

Closely allied to the emotional morbid impulse to commit 
suicide is the tendency sometimes evinced to perpetrate some 
act of mutilation on the body. Most cases of these acts are 
the result of delusions, and are effected during paroxysms of 
acute mania or of melancholia, but some are due to emotional 
impulses similar in general features to such as have first been 
considered. Further reference, therefore, to them in the pres- 
ent connection is not necessary. 

C— SIMPLE MELANCHOLIA. 

By simple melancholia is to be understood a condition 
characterized by mental depression without delusions or de- 
lirium. It is altogether an emotional disorder. ;/ The acces- 
sion is generally gradual, and though 11 it usually makes its 
appearance in those who are naturally grave and reserved, 
yet this is by no means always the case, and a radical change 
of disposition and character is hence effected. 

Perhaps the earliest symptom of the disorder in question 
is a perverted and exaggerated degree of impressionability to 
all excitations from without and reflections from within. Not 
only do such factors, when naturally of a depressing charac- 
ter, exercise their logical influence to an extreme degree, but 
those, which to mankind in general are pleasing, produce also 
emotions of sadness or sensations of pain. The least thing, 
therefore, suffices to disturb the equanimity of the patient, 
and to excite melancholic trains of thought which haunt him 
long after the cause should have passed into oblivion. By 
strained processes of reasoning he misinterprets the most in- 
different circumstances as having been specially contrived for 
his discomfort or unhappiness, and construes acts of kindness 
into insults or injuries./ As those with whom he associates 
are not generally disposed to bear with his fretfulness, his re- 
proaches, his accusations, he avoids them as far as he pos- 
sibly can, and, withdrawing from society, even that of his 
own immediate family, broods in silence, and often in secret, 



SIMPLE MELANCHOLIA. 455 

over his own gloomy thoughts. Although in this uncompli- 
cated form of melancholia the individual shows no tendency 
to imbibe actual delusions, he constantly exaggerates the na- 
ture and consequences of his own acts and of those of others. 
Thus, if he has been somewhat wild in his youth, he is now 
sure that the results of his early indiscretions are making 
their appearance, and that punishment awaits him both in 
this world and in the world to come. If he has committed 
errors in his business, though they may really have been of 
no great consequence, he brings himself to the belief, or at 
least the fear, that immediate financial ruin is staring him in 
the face. If he has money invested, or commercial or other 
transactions in hand, he is certain the one will be lost, and 
the others will result unfavorably. He is, therefore, su- 
premely unhappy, and the state of his mind is exhibited in 
every feature of his countenance, and shown in every gesture 
that he makes. He weeps, sobs, wrings his hands, groans, 
sighs, and laments in the most sorrowful accents, the cruel 
fate which has come upon him. He wishes he were dead ; 
the grave would be a relief ; and yet he knows that beyond 
this life there are greater sorrows in store for him. 

Occasionally there are tendencies to suicide, but these are 
the result of reflection, and formed after what to the patient 
is a thorough survey of all the circumstances of his case, and 
as a consequence of the conclusion that death would be a re- 
lief. ! ' If he does not attempt self-destruction, it is because of 
his doubts as to the future, because he lacks the physical 
courage necessary to the act, because of the sorrow that his 
family would feel, or of some other rational motive. He 
often wishes he could so arrange matters that he could at 
once end an existence that has become too burdensome to be 
longer borne, and will sit for hours with the means of instant 
death in his hands, trying to make up his mind to bring his 
life to an immediate termination. 

The intense mental depression which exists in these cases 
cannot fail to influence, with more or less effect, the other 
categories of mental faculties, though it may not bring them 
to actual aberration. Thus, the force of the intellect and the 
power of the will are generally indubitably weakened. The 
individual may be able to reason acutely enough in regard to 
matters with which he is familiar, and may, with a sort of 
spasmodic energy, conduct himself with credit in a dispute or 



456 DESCRIPTION AND TREATMENT OF INSANITY. 

an argument of short duration, but he is incapable of long- 
sustained mental effort, and unequal to the task of investi- 
gating subjects new to him. 'Indeed, the mental concentration 
necessary to such pursuits is rendered impossible by the pre- 
occupation of his mind. How, for instance, can a man study 
a new field in philosophy or work out an abstruse mathe- 
matical problem when his emotions excite in him thoughts 
of financial ruin, desertion by his wife and children, or the 
damnation of his eternal soul ? 

From a very early period in the course of the disease there 
are marked physical symptoms. The patient sleeps badly, 
both as regards quantity and quality ; there are dreams often 
of a frightful character, and always unpleasantly vivid. There 
are pains in the head, and other sensations, which, if not 
amounting to actual pain, are such as to cause discomfort. 
There is a sense of fulness, or of tightness, or of weight, always 
induced during any particularly marked paroxysm of emotional 
disturbance or period of intellectual exertion. The mouth is 
dry, and is liable to have a bitter taste form in it when the 
patient is unusually troubled. The cutaneous perspiration 
is diminished. The urine is likewise lessened in quantity, 
and the bowels are ordinarily obstinately constipated. The 
appetite is almost entirely abolished, and not only that, but 
food of all kinds may excite the greatest degree of repug- 
nance. Unusual persuasion is, therefore, often required to 
induce the individual to eat, and it may become necessary to 
resort to forcible means of feeding in order to ensure the 
proper nutrition of the patient. 

The mental hebetude has its counterpart in the condition 
of the body. There is an indisposition to move, even in the 
presence of such circumstances as render motion necessary 
to the life of the subject. Thus, in a case the particulars of 
which I am familiar with, an old gentleman, who had been 
the subject of simple melancholia for several years, refused to 
get up from bed, though the house in which he was had taken 
fire. "Let it burn!" he exclaimed; "I am glad of it. I 
will go with it," and he persisted so obstinately in his deter- 
mination that he had to be removed by force. 

There seems to be in many subjects of simple melancholia 
a tendency to wasting of the body, even though they may be 
sufficiently well fed. In others, again, there is a decided dis- 
position to the accumulation of fat. 



SIMPLE MELANCHOLIA. 457 

In women, the menstrual function is generally deranged, 
either by its irregularity as regards periodicity or quantity 
or by its complete suppression. 

Although the subjects of simple melancholia generally ex- 
hibit some degree of cutaneous hyperesthesia, this is in most 
cases a phenomenon of the earliest stage of the affection. Later 
on there is a decided blunting of the sense of touch, of that 
of pain, and of other excitations made upon the skin. Chris- 
tian ' has pointed out this fact in a very thorough manner, and 
has shown, through his researches, that melancholies of all 
kinds are often insensible to impressions which in normally 
constituted persons would give rise to the most agonizing 
pain. "I have seen," he says, " a melancholic open his belly 
with a nail ; another, with a dull knife, extirpate his testi- 
cles ; and a third cut off his thumb with a hatchet. I have 
at this time under my care a man, thirty-three years of age, 
who has been deranged for seven years with lypemania, who 
crushed his left hand by placing it on a rock and pounding 
it with a big club. All the fingers have their bones broken. 
It was necessary to amputate several phalanges and to extract 
a great many pieces of bone, during which operations the 
patient did not seem to feel the slightest pain." 1 

At times, under the influence of the depressing emotions 
which crowd upon him, or as a consequence of the abuse to 
which he has put his organs, the subject of simple melan- 
cholia may commit some frightful act of self -mutilation. A 
man within my own experience, a carpenter and a good work- 
man, got out of work and became melancholic. Reflecting 
upon his condition and his inability to get anything to do, he 
called to mind the fact that a former employer had repri- 
manded him for some mistake he had made. He brooded 
over this circumstance till he decided that, as he was not fit 
to do good work, and that as it was to that inability the loss 
of his situation was to be ascribed, he would cut off the hand 
to which he owed his misfortunes. Moreover, had not the 
Bible said, "If thine eye offend thee, pluck it out and cast 
it from thee % " He therefore awoke one morning — and it is in 
the morning, on awaking, that all depressing emotions are 
most powerful — and, going to the wood-shed in the yard at 
the back of the house, laid his right hand on a log, and with 

1 "Etude sur la melancolie. Des troubles de la sensibilite geDerale chez les 
melancoliques." Paris, 1876. 2 Op. cit., p. 31. 



458 DESCRIPTION AND TREATMENT OF INSANITY. 

an axe cut it off at a single blow. He was found shortly 
afterward nearly dead from the loss of blood. 

M. Soulier 1 has reported the case of an old sergeant of 
the army who was found one morning lying in his tent bathed 
in blood, and in a state of extreme prostration. At one side 
lay his penis and testicles, which he had cut off with a sharp 
clasp-knife. Nothing very satisfactory could be got out of 
him by questioning. He did not get drunk, and he was highly 
esteemed by his officers. It was called to mind, however, 
that for several days previously he had been unusually taci- 
turn, and had avoided his comrades. He seemed to be dis- 
turbed at the idea that his military life was drawing near its 
close. A light admonition of the sergeant-major had caused 
him to shed tears. M. Sourier conceived that the man, arriv- 
ing at the conclusion that he was approaching that age at 
which he would have to leave the military service, had become 
melancholic, and had, in a spirit of exaggeration, cut off his 
genital organs, in order to make himself still more unworthy. 
As he says, quoting Lisfranc, "Man places his dignity in the 
virile organs." 

It is not always the case that simple melancholia is of 
gradual accession. On the contrary, it may make its appear- 
ance with great suddenness, either as the direct consequence 
of some severe mental shock or as a sequence of some bodily 
disease or injury. Dr. Dickson 2 mentions the case of a lady 
who was expecting the return of her husband from India, and, 
anxiously watching for his arrival, was informed by a relative 
of his death. She uttered a loud scream, but never spoke 
again, and sank into a profound melancholy, from which she 
never recovered. 

Dr. Conolly, 3 in calling attention to the fact that melan- 
cholia, though usually a disease of slow growth, may super- 
vene suddenly, cites the following case : 

" A young gentleman, who appeared to be in perfectly 
good health, dropped down dead while walking in his moth- 
er's garden. His mother became speechless and almost im- 
movable, and long remained so ; and to this state succeeded 
in a few weeks a profound melancholy, which lasted many 

1 " Recueil des memoires de medecine de chirurgie et de pharmacie militaires," 
Paris, aout, 1869. 

2 " The Science and Practice of Medicine in Relation to Mind," New York, 
1874, p. 179. 3 « The Croonian Lectures " for 1849, London, p. 23. 



SIMPLE MELANCHOLIA. 459 

months, during which she accused herself of being unpardon- 
ably wicked and despairing of God's mercy, but never alluded 
to the death of her son." 

In a recent case, in regard to which I was consulted, and in 
which the accession of the disease was extremely sudden, 
there was a like oblivion of the cause of the mental disturb- 
ance. In this instance, the patient, a gentleman advanced in 
years, was abruptly informed that his daughter, a married 
woman, had eloped, with a disreputable man, from her hus- 
band and children. A state of profound melancholy was at 
once induced, and for several days not a word was uttered ; 
neither did the patient stir from his chair, nor eat a mouthful 
of food. His mental faculties appeared to have been com- 
pletely stunned. Gradually, however, he, in a great measure, 
recovered from this state of profound hebetude, but he re- 
mained all his life the subject of deep melancholia, weeping 
and wringing his hands, and pacing the floor of his apartment 
day and night, in a state of the most profound grief. He was 
apparently filled with remorse for his past life and with ap- 
prehensions for the future, but he never once alluded to his 
daughter or her conduct. He had, among other functional de- 
rangements, absolute anorexia, and would not eat unless un- 
der great persuasion, or preparations to force him were made. 

Then, with the protest that it was ' ' a shame to make a 
man eat who did not want to eat," he would gulp down his 
food without apparently tasting it, and, with a sigh of relief, 
express the hope that he would now be left alone to think 
over his wickedness. 

It is almost invariably the case that the subjects of simple 
melancholia are worse early in the morning than at any other 
period of the day, and that there is a gradual alleviation as 
night approaches. This fact is one which exists even with in- 
dividuals whose minds are free from disease. If there is any 
unpleasant circumstance which is causing mental distress, its 
action is always more powerful in that state in which the in- 
dividual, as morning approaches, is half awake. Those mel- 
ancholies who commit suicide are much more apt to do so in 
the morning, soon after they have risen from bed, than at any 
other time. The course of simple melancholia is often toward 
one of the other forms of the affection next to be described. 
It is not infrequently cured, or terminates spontaneously in 
recovery. Again, it may pass into a chronic condition, with or 



460 DESCRIPTION AND TREATMENT OF INSANITY. 

without an alleviation of the more marked symptoms. In 
the case of a woman affected with simple melancholia, unat- 
tended by delusions of any kind, the affection had lasted over 
twenty-five years without any notable change in the symp- 
toms except in regard to the tendency to suicide, which she 
had at first exhibited, but which has been absent for many 
years. There was no obvious cause — not even heredity — for 
the intense melancholy with which she is affected, and which 
causes her to pass the greater part of the day crying and 
wringing her hands. She had twice attempted suicide before 
she came under my observation, not from any delusion, but 
solely in order that she might escape from her intense mental 
depression. She is perfectly conscious of her situation, knows 
how groundless is her grief, and constantly laments her ina- 
bility to control her feelings. She is now about fifty years of 
age, is unmarried, and has never suffered from menstrual or 
uterine disorder. The menopause occurred in her forty-fourth 
year. 

d — MELANCHOLIA WITH DELIRIUM. 

Melancholia with delirium is that form of mental aberra- 
tion in which there is emotional depression conjoined with il- 
lusions, hallucinations, and delusions, singly or combined, to- 
gether with incoherence of words and ideas, and more or less 
increased motility. It is sometimes designated acute melan- 
cholia, and by the French alienists is known as lypemanie 
avec delire or melancholie avec delire (lypemania or melan- 
cholia with delirium). It is, from whatever point it is re- 
garded, one of the most terrible of all the forms of mental 
aberration. 

Generally, melancholia with delirium begins with well- 
marked prodromatic symptoms, which do not differ essentially 
from those met with in other varieties of insanity except in 
the circumstance that the mental depression is more pro- 
nounced. From a very early period the patient sleeps badly, 
and is troubled with unpleasant dreams. He usually suffers 
from pain or other feeling of discomfort in the head, his 
stomach is deranged, his breath offensive, his bowels consti- 
pated, and his urine scanty and high-colored. 

At about the same time changes in his habits and modes 
of thought are observed ; he becomes gloomy and taciturn, 
shuns those with whom he formerly associated with pleasure, 
and imbibes the idea that his friends and relatives are want- 



MELANCHOLIA WITH DELIRIUM. 461 

ing in proper respect for him, or are positively maltreating 
him. 

His countenance undergoes a change in accordance with 
the alterations which are being effected in his mind and body ; 
his expression is absent, as if the thoughts were engaged with 
subjects not in relation with passing events, while at the same 
time there is a disquietude and apprehension exhibited which 
are evidences of the feelings within. The forehead is wrinkled 
— a characteristic feature ; the head is slightly inclined for- 
ward, and the lips are firmly compressed. The movements 
of the body are sudden, and are often made without any ap- 
parent object, however much they may be in accordance with 
the thought. A patient of my own, for instance, walked con- 
tinually from one corner of the room to the other diagonally. 
When asked why he did this, his only answer was a look ex- 
pressive of contempt for the questioner. Evidently there 
were reasons in his own mind for his peculiar movements, 
which he disdained to reveal to those whom he thought were 
actuated by impertinent curiosity. 

The tendency to silence is often very strongly marked, 
and perhaps as often alternates with periods of great loqua- 
city. During a paroxysm of taciturnity the patient appears 
to be in a state of active thought, and will frequently, by 
his gestures, give expression to the ideas which are passing 
through his mind. If spoken to, however, he preserves an 
obstinate silence, though his face may show his anger at being 
interrupted in his process of thinking. When disposed to 
talk, he rambles from one subject to another, but all his 
words are expressive of the delusions which are beginning to 
find a lodgment in his mind. He talks of the combinations 
which are being formed against him, of the great sins he has 
committed, of the fatal diseases with which he is affected, of 
the losses he has sustained in his property, of the treachery 
of his friends, and so on — everything of which he speaks 
being an evil, a misfortune, a degradation, to which he has 
been subjected. 

Illusions and hallucinations make their appearance. Real 
sounds and real images are misinterpreted, for instance, into 
the voices of demons summoning him to punishment, or the 
forms of the demons themselves coming to convey him to 
hell. Hallucinations of hearing and sight are still more com- 
mon. He hears voices urging him to do some act of violence — 



462 DESCRIPTION AND TREATMENT OF INSANITY. 

often murder or suicide, or reproaching him with the unpar- 
donable character of his sins, and revealing the terrible nature 
of the punishment he is to undergo in the next world. A 
patient of mine, on going to bed, had the hallucination of a 
voice, apparently, as he said, just outside the house, call- 
ing to him to come : " Come to me ! come to me ! Do not 
wait ! Come ! come ! you are mine ! I claim you now ! Come ! 
come ! " and this for over an hour, till, wearied with the im- 
portunity, and at last accepting the hallucination as a verity, 
he sprang from his bed and rushed from the house into the 
cold winter air. 

Another heard a voice, apparently, close to his ear, urging 
him, by every holy and reverent name, to save his soul by 
thrusting his hand into the fire. " This, "it said, " will make 
your peace with God. This will secure your salvation. It is 
better to go to heaven with one hand than to enter hell with 
two. It is a bad hand. You have committed numberless 
crimes with it. Burn it off, and be done with it forever ! " 
For hours he resisted. " I will not burn my hand," he said. 
"God cannot demand such a sacrifice of me. !No, no, I will 
not ! You are a devil ! O God, deliver me from this demon ! " 
But hours passed, and still the voice was crying in his ear, 
" Burn your hand ; it is a wicked hand ! " The night was far 
spent ; he had not closed his eyes in sleep ; wearied in mind 
and body, he little by little accepted his hallucination for 
reality, and, rising from bed with a prayer to God on his lips, 
he thrust his hand into the fire that burned upon the hearth, 
and held it there till the flesh was charred into a black and 
shapeless mass. 

At first, hallucinations of hearing are present only at 
night, but, as the disease advances, they occur also in the 
daytime, and then are rarely absent. Not infrequently they 
are associated with real personages, who may or may not be 
present, but usually they appear to come from indeterminate 
beings — angels, demons, or personages coined altogether from 
the imagination of the patient. Thus, a young lady affected 
with the disease under consideration heard voices coming, 
apparently, from two persons, male and female, whom she 
designated " Busho " and " Quampa," and which told her that 
her mother wished to poison her, that her brother had hired 
a man to commit a rape upon her, and that, in order to escape 
a painful death and overwhelming dishonor, she ought to 



MELANCHOLIA WITH DELIRIUM. 463 

drown herself in the bath-tab. They even prescribed how 
the drowning was to be effected. "Fill your mouth full of 
cotton batting," said " Busho," "fasten the dumb-bell you 
use, about your neck, then turn on the water, and lie down in 
the tub." "Hot water, boiling water ! " interrupted " Quam- 
pa." "It will do the work quicker, and will not be so pain- 
ful." She resisted these commands, and was fortunately 
placed under restraint before she reached the stage of accept- 
ing them as real orders coming from persons with the right to 
be obeyed. 

Hallucinations of sight, though not probably so common 
as those of hearing, of cen coexist with them. They may re- 
late either to persons in a state of action or repose, or to 
things of a more or less terrifying character. There may be 
the image of a man approaching in a menacing attitude, with 
a murderous weapon in his hand, or representations of scenes 
of torment typical or anticipatory of the fate in store for the 
victim. As the night is often passed without sleep, it is then 
that hallucinations of sight, like those of hearing, are more 
common. Long rows of horrible characters pass in endless 
procession before the strained and wearied eyes ; pictures of 
a vividness scarcely ever realized in life are presented, in 
which the most horrible acts are being committed by person- 
ages of frightful mien. Again, the scenes may be of saints 
of the church who are being tormented by heathens, and who 
call in agonizing tones on God for strength to bear their tor- 
tures with fortitude. 

Hallucinations of touch, though not so frequent as those 
of sight and hearing, are, nevertheless, not uncommon. A pa- 
tient of my own, a lady, with strong hereditary tendency to 
insanity, and who was herself the subject of melancholia with 
delirium, frequently had the sensation of a hot blast of wind 
blowing over her face, and which she imagined, from its in- 
tense heat and sulphurous smell, came from the prince of 
darkness, who was bending over her. Again, there may be 
sensations as though the body were being packed in ice, 
plunged into boiling water, or torn with red-hot pincers. A 
man affected with the disease in question informed me that 
every night a devil came and broke all his bones with a crow- 
bar, and that during the day "the chief physician of hell" 
set them all, so as to have them ready to be broken again at 
night. Sometimes the hallucination connects the pains with 



4G± DESCRIPTION AND TREATMENT OF INSANITY. 

some particular person, when the patient has the false per- 
ceptions of seeing and of hearing. 

Hallucinations of taste may give rise to the delusion that 
poisoning the food is being attempted, or that it is rotten or 
otherwise unfit for use, and hence there is an obstinate re- 
fusal to eat. In the patient whose case has just been cited 
there was often the hallucination of the taste of oil of bitter 
almonds in his tea or coffee, and even at times in the water 
he drank. 

Hallucinations of smell are the least common of all. Oc- 
casionally, however, they are very persistent, and give rise to 
troublesome delusions. Thus, a patient, whose case I have 
mentioned in another chapter, had the hallucination, among 
others, that the masons met in their lodges all over the coun- 
try, and, by means of pipes leading from their rooms to his 
own, sent out all kinds of poisonous vapors for him to in- 
hale. Upon one occasion he sprang from the bed in the 
middle of the night, exclaiming that a glass bomb full of 
poisonous vapor had been thrown in at the window, that it 
had broken in its fall, and that he was dying of suffocation. 
He declared that the odor was that of rotten fish, and that 
phosphorus entered into its composition. 

As already said, the subjects of melancholia with deliri- 
um are among the most dangerous of all lunatics ; the de- 
lusions which they entertain are to them as real as though 
based on actual facts, and they are accordingly guided by 
them in the same degree as they would be were they the 
most irrefragable truths. When, therefore, for instance, a 
man suffering from melancholia with delirium thinks he 
hears the voice of God commanding him to kill his wife 
and children, he unhesitatingly obeys, thinking that he has 
received an order from a superior being, to disobey whom 
would be a heinous sin. It was thus that Freeman, two or 
three years ago, killed his child as a sacrifice to the Deity. 

Again, the patient may have exhibited no very striking 
evidences of mental derangement — not striking, at least, to 
superficial or ignorant observers — when suddenly an exacer- 
bation of intense delirium occurs, and some terrible crime is 
committed. 

A few years ago a horrible crime was perpetrated on Ber- 
gen Heights, a part of Jersey City. A policeman, entering 
the house of a laboring man, found the dead bodies of three 



MELANCHOLIA WITH DELIRIUM. 465 

children lying on the floor with their throats cnt. In the 
corner stood the mother, looking placidly at her mnrdered 
children. "I killed them," she said, in answer to the ques- 
tions of the officer ; "I cut their throats with a razor, because 
I wanted to send them to heaven. They were sick, and I was 
sick, and I wanted to die with them." 

Subsequently the father told the full details of the hor- 
rible affair. "I saw my wife," he continued, after telling 
how he had found the dead bodies of his children, ' ' standing 
near the crib with a razor in her hand. I said, ' Good God ! 
Mary, what have you done with the children ? ' She answered, 
' I killed them with your razor.' I asked, ' Why did you kill 
them \ ' and she said, ' Because everybody said they were 
little devils, and I wanted to send them to heaven.' " 

In answer to the question of the reporter, the father said 
that for five years his wife had been sickly. She was about 
forty years of age, and had never drank liquor. Since her 
sickness she was at times peevish, and sometimes acted 
strangely, but not enough to justify him in suspecting that 
her mind was affected. A few years ago, he said, she often 
used to remark that she was going to die soon, but lately she 
had not used that expression. 

In the early part of the present year a woman in Milwau- 
kee killed her three children in a most brutal manner, literally 
hacking them to pieces. The attention of the neighbors was 
attracted to the scene by the woman's attempt to hang herself 
in an outhouse. They cut her down and brought her into the 
house, where the most horrible spectacle was discovered. The 
woman, Mrs. B., was at once arrested. She took her arrest 
very calmly, stating that she had read in the good book that 
it was right to sacrifice children. The children were all girls, 
and were aged respectively four years, twenty months, and 
four months. When a reporter reached the apartment in 
which the deed had been committed, he beheld a terrible 
sight. At the left of the door stood a large, low bed, and 
on the scanty, dirty bed-clothing lay the forms of three little 
girls. Their bodies were naked, and were cut in a ghastly 
manner. The eldest girl had a large number of gashes, 
made with a butcher's knife, all over her body. The arms 
of the second girl were cut off near the shoulders, and the 
legs hung to the body by thin shreds of skin and flesh ; the 
body was completely disemboweled. The body of the babe 

30 



406 DESCRIPTION AND TREATMENT OF INSANITY. 

was cut up into six pieces, the head and extremities being 
completely severed from the trunk. Near the foot of the bed 
a young woman, only partially dressed, and with dishevelled 
hair, crouched on. the floor, held down by two strong men. 
She was the murderess. Her hands were bloody, and the 
front of her dress was saturated with blood. An unnatural 
smile played about her mouth, and her whole appearance 
was that of an insane person. 

"When placed before the fire in the police station, she told 
her story in broken German. When asked how she murdered 
the children, she replied that she stabbed one of them in the 
breast and the other in the shoulder, and that they cried but 
little, as she made quick work of the butchery. She smiled 
as she pronounced these last words. She used a drawing- 
knife and two small carving-knives. With the former weapon 
she had shaved the children's bodies as a cooper would a 
stave, and with the latter disemboweled them. While the 
bodies were shockingly mutilated, the heads were untouched. 
When asked what had caused her to do the fearful deed, she 
replied, " I read it in the book." She thought she had made 
a great sacrifice. She kept smoothing her back hair with her 
bloody hands, and looked at the crimson stains and smiled. 
Her eyes had a wild look. 

In answer to a question as to whether his wife had shown 
any symptoms of insanity before that morning, the husband 
answered that she had not. He then recollected that at about 
Christmas time she had read something in a paper that seemed 
to have a great effect upon her. Since then she had spent 
whole days in looking at a small prayer-book on her lap, 
cooking no food, and not even heating the room. She had 
worried a great deal because the sickness of the children had 
prevented her attending church. 

The delusions of the subjects of melancholia with delirium 
are either variable or fixed. If the former, they change gener- 
ally only within certain limited bounds, being of similar char- 
acteristics, though perhaps differing in details. In the early 
stages of the affection they are more apt to be varied than in 
the later periods. 

A symptom to which Poterin du Motel ' has called atten- 

1 " Etudes sur la melancolie," etc., " Memoire couronne par l'academie iraperi- 
ale de medecine, Memo-ires de Tacademie imperiale de medecine," t. xxi, 1857, 
p. 510. 



MELANCHOLIA WITH DELIRIUM. 467 

tion is intellectual obliteration, or micromania, as lie proposes 
to designate it. It is a tendency to attach importance to in- 
significant circumstances ; a disposition to be abnormally 
minute, puerile even, in all their mental operations and char- 
acteristics. The woman whose case has just been given ex- 
hibited this symptom when she brought herself to murder her 
three children because she had read in the "good book" that 
it was right to kill children. In others some trifling circum- 
stance, as for instance the delivery by the baker of two loaves 
of bread on any one morning instead of one, is construed into 
a deep-laid plan on his part to poison the family. The occur- 
rence of a particular word two or three times on a page was 
deemed by a patient of my own a sufficient reason for at- 
tempting suicide. When asked what connection there was 
between the word witch and the act of self-murder, she re- 
plied that she was a witch, and that the Bible had declared, 
" Thou shalt not suffer a witch to live." 

In such cases there is no logical relation between the prem- 
ise and the conclusion, and the former is altogether inade- 
quate to justify the acts committed, even if they were logi- 
cally connected. 

Crimes are, as we have seen, often committed by the sub- 
jects of melancholia with delirium under the influence of 
supposed commands from the Deity, or through the misinter- 
pretation of passages in the Bible. Such would appear to 
be performed from a high religious sense, and from a feeling 
of duty to the Creator of the universe. Occasionally, how- 
ever, there is the incentive of fear, and orders to kill, imag- 
ined to emanate from the devil, are probably due to this cause. 
Thus, a patient in Bethlehem Hospital became deranged 
from unknown causes, and killed one of her children, seven 
months old, by severing its head from its body. She was 
tried for the fact at the Old Bailey, and acquitted on the 
ground of insanity. She believed that the devil had directed 
her to do the deed. She was sent to the lunatic asylum in a 
very violent and dangerous state. She made several attempts 
to commit suicide, tearing the sheets and blankets into strips 
with which to strangle herself. All strings had to be removed 
from her clothes. She attacked every one who came near, 
but frequently spoke of her dead child in an affectionate 
way, and cried bitterly night and day. Finally she stopped 
talking, with the exception of answering every question 



468 DESCRIPTION AND TREATMENT OF INSANITY. 

with the phrase, "Forever and a day, as the boy sold his 
top." 1 

In another case 2 of similar characteristics, the patient, a 
woman twenty-eight years of age, had been a servant in a 
family, bnt had "got religion," and in a little time lapsed 
into melancholy and despair. She had a constant habit of 
biting her nails and the ends of her fingers, and lacerating 
her flesh for the purpose of mortification. 

She was so merged in despondency and ntter hopelessness 
that she firmly believed the devil was to have her when she 
should die ; that the evil spirit had all the power, and the 
Deity none ; that, seeing it impossible to be saved, she had 
given herself up to live in wickedness and idleness, and that 
all this was occasioned by her not believing in God. That she 
was never more to be happy, but was to be tormented forever 
and ever. This was the constant tenor of her lamentations 
from morning till night. She could not be induced to repair 
any part of her clothes, nor even to mend a hole in her stock- 
ing, wash her skin, or do anything whatever that could con- 
tribute to her own health or comfort, not so much even as to 
change her linen, unless when forced to do so. This patient 
finally recovered, as the sequence of a severe bodily illness, 
the nature of which is not stated. 

Melancholia with delirium is generally characterized by 
the presence of remissions in the violence of the symptoms, 
during which periods the patients are free from excitement, 
and, if not disturbed, appear to be greatly improved. Some- 
times there are distinct intermissions, and at these times there 
is such manifest change, not only as regards the delirium and 
the delusions, but even in the matter of the mental depres- 
sion, that anticipations of recovery are entertained. Patients 
will then speak of their own state, and are fully aware of the 
former existence of mental aberration. Occasionally there is 
a well-marked periodicity in the occurrence both of remis- 
sions and intermissions. 

The present appears to be the proper place to speak of a 
remarkable symptom sometimes met with in melancholia with 
delirium, and in other forms of insanity, and that is Ticema- 
toma auris, or bloody tumor of the ear. This may be de- 
scribed as an effusion of blood within the cartilage of the ear, 
or between the cartilage and the perichondrium. This extra- 

1 " Sketches in Bedlam, 11 London, 1823, p. 287. 2 Op. cit., p. 278. 



MELANCHOLIA WITH DELIRIUM. 469 

vasation becomes encysted, and may remain in this condition 
for a considerable period. Eventually it is generally absorbed, 
and with its disappearance the ear shrivels and becomes dry 
and hard. There is another species of tumor of the pavilion 
of the ear, first described by Fischer, which consists of an 
effusion of serum, and which is a mild affection compared to 
the other. 

Bloody tumor of the ear is more frequently met with in 
insane men than women. It is more common in all the forms 
of melancholia, in general paralysis of the insane, and in acute 
mania, than in other varieties of mental derangement. It 
may occur only in one ear, or both may be affected, and the 
left ear is more liable than the right. Its appearance is re- 
garded by some authorities as of bad augury, so far as relates 
to the prognosis. 

The origin of hsematoma auris has been a matter of ani- 
mated discussion. The fact that the left ear is the one gen- 
erally affected has led to the conclusion, on the part of some 
alienists, among them G-riesinger, that it is the result of 
pinchings or blows from attendants, or by the patient knock- 
ing his head against the bed-posts or other hard substance. 
Griesinger, 1 indeed, asserts that the impression of the finger- 
nails is sometimes observed, and that the affection can, by care 
on the part of the attendants, be made entirely to disappear 
from well-regulated asylums. 

Biaute, a in a memoir published in 1877, asserts that alien- 
ists — meaning by the term the medical officers of asylums — 
do not admit that these tumors are ever of traumatic origin. 
In a subsequent paper he 3 cites several cases of blows received 
by lunatics on the ears without the production of hematomas. 

On the other hand, again, M. Bouteille, 4 in an elaborate 
memoir, in which the opposing views of many authors are 
given, shows that it is by no means a prognostic sign indicat- 
ing a fatal termination, and that it is the result of traumatism. 
He says : 

" To resume, bloody tumor of the ear in the cases of boxers 

1 "Menta] Pathology and Therapeutics," New Sydenham Society Translation, 
p. 438. 

2 " Observations sur les tumeurs sanguines du pavilion de l'oreille," An- 
nates medico-psychologiques, mai, 1877. 



Note sur les traumatismes de Poreine," op. cit., juillet, 1882. 
Tumeurs sanguines du pavilion de l'oreille, " op. cit., juillet, 1878. 



470 DESCRIPTION AND TREATMENT OF INSANITY. 

and lunatics presents the same symptoms, the same clinical 
history, the same deformation of the ear, and the same thera- 
peutic indications. In boxers it results from a traumatic 
cause, and the origin in lunatics is the same. 

" Without wishing to reject absolutely the alleged predis- 
posing causes, we think they have not the value which has 
been attributed to them, and that hematoma only appears as 
the consequence of injuries inflicted on the ear by the pa- 
tients themselves or by others. The affection as regards its 
prognostic value is of no importance." ' 

The truth is probably to be found in the facts that the 
insane condition acts as a powerful predisposing cause, that 
traumatism of slight character is competent to produce he- 
matoma auris, and that its origin is to be found in the blows 
and other injuries inflicted by the patients themselves, by 
other patients, or by attendants. 

Reference has already been made to the circumstance that 
the subjects of melancholia with or without delirium are par- 
ticularly prone to refuse food. This act may be based upon 
one of three causes : (1) The patient has a delusion that the 
food given him is poisoned, and that if he takes it he will 
die ; or (2) he refuses to eat because he desires to commit 
suicide, and finds in starvation a ready means ; or (3) he does 
not eat because he has no appetite. It is important as regards 
the treatment that the physician should ascertain which of 
these is the governing motive. 

In an interesting essay, M. Mabille a shows that there is 
often present in melancholies a sensory paralysis, partial or 
total, of the alimentary canal, and that this paralysis appears 
after they refuse food. He attributes it to nervous exhaus- 
tion from emptiness of the stomach, and to the sudden disten- 
tion which the organ undergoes through the process of forcible 
feeding to which sitophobics are usually subjected. 

Melancholia with delirium may terminate in complete re- 
covery, or it may pass into the condition next to be described, 
or into chronic mania, or death may take place from suicide, 
exhaustion, or from the supervention of some other acute 

1 M. Bouteille is the physician in chief of the insane asylum at Armentieres, 
and professor (agr6g6) of the faculty of medicine at Lisle. His opinions on the 
subject cannot be suspected of bias against the asylum interest. 

2 u Etude clinique sur quelques points de la lypemanie," Ann. med. psychol., 
mai, 1880, p. 345. 



MELANCHOLIA WITH STUPOR. 471 

or chronic brain disease. The duration of the disease is, 
therefore, variable. I have known cases to be cured in less 
than three months, and others last, with but little diminution 
in the intensity of the symptoms, for several years. The 
duration and general course of the affection are greatly in- 
fluenced according as the medical and hygienic management 
of the patient is good or bad, and the hereditary tendency 
weak or strong. Under advantageous circumstances, a short 
duration and a favorable termination may reasonably be ex- 
pected, even in very violent cases. But under bad manage- 
ment, or with a marked heredity, slight cases do badly. 

e — MELANCHOLIA WITH STUPOE. 

Melancholia with stupor — the melancholia atonita of the 
ancients, and the acute dementia of English writers — owes its 
thorough study, like so many other mental diseases, to the 
alienists and psychologists of France. 

Georget, 1 under the name of " stupidite," described the 
condition in question as one in which there was a suspension 
of the cerebral faculties, confusion of ideas, and an obtusion 
of the intelligence. 

Etoc-Demazy, 3 in 1835, published a work on the subject, 
in which he refused to recognize " stupidity" as a distinct 
form of insanity, declaring that it was only a complica- 
tion met with in certain cases of monomania and mania. 
According to him, it consists of a simple diminution of 
the sensory, intellectual, and moral faculties. He further 
expresses the opinion that the condition in question is due 
to an intracranial infiltration of serum, the flattening of the 
convolutions of the brain, and the tension of the dura 
mater. 

But the views at present generally entertained relative to 
the nosological position of " stupidity" are based upon a 
work published by Baillarger s in 1843. The author describes 
" stupidity" as characterized by confusion of the ideas, per- 
ceptions, and sensations, and by the existence of general de- 
lirium of a melancholic type. It differs from simple melan- 
cholia or melancholia with delirium by the facts that there is 
a general transformation of impressions, a loss of the identity 

1 " Considerations sur la folie," Paris, 1820, p. 115. 

2 " De la stupidite consid£ree chez les alienes," Paris, 1835. 

8 " De la melancolie avec stupeur," Ann. med.-psychol., Paris, 1843. 



472 DESCRIPTION AND TREATMENT OF INSANITY. 

of time, places, and persons, a suspension of the action of 
the will, and by the physical symptoms. 

The subjects of melancholia with stupor are in the early 
stages less profoundly affected than at subsequent periods, 
the symptoms being of gradual development. It may arise 
as a primary disease, or it may be the sequence of some other 
form of insanity. The former is more generally the case. 
When a primary disorder, it often originates suddenly, in con- 
sequence of some powerful emotional disturbance affecting 
the patient. In other cases it is developed gradually, with or 
without any apparently exciting cause. 

The individual affected with melancholia with stupor pre- 
sents a very striking appearance. He sits motionless, his 
hands clasped before him, his head bent forward, his eyes 
closed or staring vacantly, or fixed upon the floor. His half- 
open mouth allows the viscid saliva to drop from his lips. 
If spoken to, he does not answer or even give any sign that 
he has heard, and he rarely speaks spontaneously. If he 
does, he is very apt to utter some irrelevant word or sentence, 
and may go on repeating it for hours at a time, day after 
day. His movements are torpid, and rarely spontaneous. If 
told to rise, he takes no notice of the direction, but, if pulled 
up from his chair, makes only passive resistance, or none at 
all. His cutaneous sensibility is greatly diminished, both to 
sensations of touch and of pain. His expression is either one 
of absolute apathy or vacancy, or is indicative of astonishment 
or terror. The pupils are, as a rule, widely dilated. Occasion- 
ally one is dilated and the other contracted, a circumstance 
which some authors regard as an unfavorable prognostic point. 

At times tears flow from his eyes, and he exhibits all the 
evidences of grief ; and again he appears to be under the in- 
fluence of extreme fear. As stated by patients who have re- 
covered from their disease, these and other signs of intense 
emotional disturbance were due to terrible hallucinations of 
sight and of hearing, of events taking place from which they 
were powerless to escape. 

But in the most intense form of the disease there are no 
external signs of the emotions which fill his mind. He may 
be the subject of the most vivid illusions and hallucinations, 
which he accepts as realities so far as he is capable of accept- 
ing anything without the active exercise of his intellectual 
powers, but he sits impassive, as if petrified. 



MELANCHOLIA WITH STUPOR. 473 

Dagonet, 1 who lias very thoroughly considered the affec- 
tion under notice, thus graphically describes the patient suf- 
fering from this stage of melancholia with stupor : 

" When the delirium is present in a marked degree, it is 
generaUy noticed that the individual, struck as he is with stu- 
por, can be assimilated to the man who is the subject of a 
painful dream or nightmare, in which all impressions and 
sensations exercise a painful action, while he who is visited 
experiences an absolute impossibility of reacting against the 
terrors which fill his mind. 

" The patient, being entirely passive, is essentially a true 
automaton. If the events passing around him are trans- 
formed into painful impressions, as they are in those suffering 
from the systematized delirium of lypemania or megalo- 
mania, he does not, like them, submit to his diseased mental 
faculties the acts he sees or the sounds he hears, in order to 
furnish new aliment to his false convictions. His mind re- 
mains in a state of inextricable chaos, as his sensations are 
themselves in a condition of the greatest composure. With 
him all is vague and indeterminate. Deprived of the power 
of attention, he is incapable of arranging his sensorial impres- 
sions into a harmonious system, and he neither endeavors to 
understand the painful illusions of which he is the sport, nor 
to explain to himself, in a more or less logical manner, the 
extravagant circumstances in the midst of which he thinks 
he is placed. He neither reasons affirmatively nor negatively, 
for that by which he is most distinctly characterized is the 
absence of all cerebral activity, and one cannot actually affirm 
that there is any exercise of the intellectual faculties, since 
these were entirely controlled by the accidental impressions 
which he experiences. With him inertia and impotence are 
carried to the highest degree — even to the point of indicat- 
ing the absence of all thought ; to the suspension of every 
faculty. 

"The life of relation is in a great measure extinguished 
in the patient affected with stupor. He may have the most 
frightful visions, and, notwithstanding, he remains motionless, 
and in a degree impassible, in the presence of the scenes which 
cause his intense distress. He is surrounded by brigands, he 

1 " De la stupeur dans les maladies mentales et de l'affection designee sous le 
nomme de stupidite," Paris, 1872, p. 19. Also, Annales medico-psycliologiques, 
5ieme serie, t. vii, mars, 1872. 



474 DESCRIPTION AND TREATMENT OF INSANITY. 

hears the clicking of many guns aimed at him, but he does 
nothing to avoid the dangers by which he is menaced. He 
sees the fire, hears the frightful voices attendant in the confla- 
gration, but he does not stir from his place. Nothing be- 
trays the emotion which troubles him; he is, as it were, 
changed into a statue." 

In melancholia with stupor the pulse is generally slow and 
weak ; again it may be frequent, but it rarely indicates fever. 
The temperature is more apt to be slightly reduced than in- 
creased. In women, menstruation is either entirely sup- 
pressed or disordered, both as regards periodicity and quan- 
tity. 

Examined with the ophthalmoscope, the optic disk is seen 
to be paler than is natural, and the retinal vessels are straight 
and attenuated. (Edema of the disk is rarely observed in any 
but the most severe cases. 

Dr. Aldridge, 1 who, however, regards melancholia atonita 
as a different affection from acute dementia, different at least 
in degree, confirms this statement relative to the ophthalmo- 
scopic appearances in the two disorders. He finds in both, 
the optic disks pale, the retinal vessels small and shrunken, 
but in melancholia atonita there is no oedema, while in pro- 
found cases of acute dementia this condition may exist. 

The saliva is often greatly increased in quantity. In a pa- 
tient whom I saw quite recently the amount exceeded a pint 
in eight hours — a pint, that is, that flowed from the mouth 
in a vessel placed to receive it, without reckoning the quantity 
that was swallowed. The stomach sometimes rejects all food 
that may be swallowed, and the bowels are usually obsti- 
nately constipated. 

Occasionally in the first stages of melancholia with stupor 
there is a tendency to the practice of masturbation, and this, 
in my experience, is especially the case with females. During 
the more advanced periods of the disease, however, this dis- 
position disappears. In one case, that of a young woman 
brought to me by her mother, the patient did not hesitate to 
make attempts to perform the act in our presence. 

Sauze 3 asserts that "stupidity" is more frequent with 

1 " Ophthalmoscopic Observations in Acute Dementia," " West Riding Lu- 
natic Asylum Medical Reports," vol. iv, London, 1874, p. 296 et seq. 

2 "De la stupidite de sa nature psychologique et de son traitement," These de 
Paris, 1852. 



HYPOCHONDRIACAL MANIA, OR MELANCHOLIA. 475 

males than with females. It appears to be more common be- 
tween the ages of twenty and thirty than at other periods of 
life. Its duration rarely exceeds a year, and the prognosis 
in uncomplicated cases is tolerably good. It should be stated, 
however, that instances of recovery after the disease has lasted 
much over a year are rare. 

f— HYPOCHONDRIACAL MANIA, OR MELANCHOLIA. 

Hypochondriacal mania is not to be confounded with that 
much less grave affection known as hypochondria, and which 
may exist without any more serious implication of the men- 
tal faculties than a slight emotional depression. This latter 
is unaccompanied by illusions, hallucinations, or delusions, 
and is rather to be assimilated to the morbid fears already 
brought under consideration. By most authors, hypochon- 
driacal mania is regarded as a form of melancholia, and such, 
undoubtedly, is its true nosological position. 

Hypochondriacal mania is characterized by the existence 
of morbid fears relative to the health, mental or physical, by 
intense depression of mind, and by the presence of illusions, 
hallucinations, and delusions relative to the condition of the 
body, or of one or more of its organs. 

It is usually of slow development. The individual at 
first, perhaps, begins by manifesting symptoms of disordered 
bodily health. He sleeps badly, and is troubled with morbid 
dreams, which make no inconsiderable impression on his 
mind. His bowels are obstinately constipated, and there ap- 
pears to be a special proclivity to torpor of the colon and the 
impaction of faeces in that part of the alimentary canal. His 
stomach is inactive ; the food, instead of digesting in proper 
time, remains in the organ till fermentation begins, and he con- 
sequently suffers from flatulence. The liver is inactive, and 
the kidneys excrete a pale-colored urine in more than the 
normal quantity. He suffers from palpitations of the heart ; 
the respiratory act is insufficiently performed, and there is 
consequently frequent sighing. 

The mind participates in the disturbance. The patient 
secludes himself , as far as possible, from observation, renounces 
those amusements which formerly gave him pleasure, is in- 
disposed to mental exertion, neglects his business, restricts 
his conversation almost entirely to the subject of his health 
and the various sensations he experiences in different parts 



476 DESCRIPTION AND TREATMENT OF INSANITY. 

of his body, is irritable, and hypersesthetic. The least pain 
causes him inordinate suffering, the weather never suits him ; 
if his affairs go wrong, he exaggerates the difficulty ; if they 
are prosperous, the prosperity is more apparent than real, and 
disaster is sure to come in a short time. Though he has no 
idea of persecution or injury from those with whom he asso- 
ciates, he is sure that they do not appreciate the serious con- 
dition of his health. 

By degrees his conviction that he is the subject of pro- 
found disease becomes strengthened, though probably he has 
as yet no very definite notion of the nature or seat of his 
malady. Accident generally determines these points. He 
reads the details of a case of disease, he sees a person suffer- 
ing from an extraordinary affection, or he has an unusual 
sensation in some part of his body, and the bent of his mind 
is at once settled. The moment his attention is concentrated 
upon the organ which he imagines is diseased, his symptoms 
become more pronounced. Every sensation he experiences in 
it is exaggerated and misinterpreted. He is constantly on 
the watch for the symptoms which he has ascertained are 
connected with the malady which he thinks he has. He 
measures his urine, examines it by all the tests at his com- 
mand, inspects his faeces, scrutinizes his countenance in the 
glass, and, as one of my patients did who imagined himself 
to be impotent, may even take notes of the quantity, viscid- 
ity, or odor of his semen. 

He goes from one physician to another, giving long ac- 
counts, often written out, of the symptoms he has, or imagines 
he has, and takes all the medicines that may be prescribed 
with a degree of punctuality that is itself an evidence of in- 
sanity. He buys medical books on his imaginary disease, 
and brings them with him to the physician under whose care 
he is for the time being, calling his attention to certain feat- 
ures which he thinks have been overlooked, and suggesting 
the use of remedial measures which he finds mentioned. 

Up to this time his illusions and hallucinations have only 
been such as relate to visceral or cutaneous sensibility, but ere 
long the special senses show signs of perceptional derange- 
ment, sight being the one to be first, and perhaps most, pro- 
foundly affected. Any one or all of the others may become in- 
volved, and delusions soon follow. His life is now a perpetual 
source of misery to him. He thinks, talks, dreams of noth- 



HYPOCHONDRIACAL MANIA, OR MELANCHOLIA. 477 

ing but himself and his diseases. He experiments with the 
most extraordinary agents which he imagines may restore 
him to health, and, obtaining only failure, tries others still 
more fanciful. In his moments of despair he may talk of 
suicide, but it is generally only talk ; he rarely attempts it. 
Indeed, with the misery and sorrow which so strongly affect 
the patient, there is a predominating love of life which stands 
in the way of all tendency to self-destruction. 

Dubois ' divides the symptoms of hypochondria into the 
period of invasion and three periods of the fully developed 
disease, but he fails to make sufficient distinction between 
those cases which are simple hypochondria, and which never 
pass into a more fully developed stage, and those which very 
surely and rapidly tend to the further implication of the 
mind. He, however, recognizes the fact that there is a dis- 
tinct form of mental aberration characterized by the exist- 
ence of perceptional, intellectual, and emotional derangement. 
Of this he makes three varieties, named according to the part 
of the body associated with the physical and mental disturb- 
ance — hypochondriacal monomania, pneumo-cardiac mono- 
mania, and encephalic monomania ; and three other forms, 
which would scarcely at the present day be considered hypo- 
chondriacal — the asthenic, the nostalgic, and the hydropho- 
biac. 2 

His division into periods is, however, better founded, and 
is a natural arrangement of the symptoms of hypochondriacal 
mania. 

The first period is characterized by the existence of purely 
mental symptoms. There are no obvious physical derange- 
ments, and, if there are any such, they are entirely subjective. 

In the second period there is the same mental condition, 
but there are functional troubles of various organs of the 
body. 

And in the third period there is superadded to the fore- 
going categories of phenomena lesions of the organs, either in 
the nature of congestions, inflammations, or other more serious 
affections. Real disease is, therefore, induced, and the symp- 
toms are such as are peculiar to the existing lesion. 

The illusions, hallucinations, and delusions of hypochon- 
driacal maniacs are among the most remarkable and prepos- 

1 " Histoire philosoplrique de Thypochondrie et de l'hysterie," Paris, 1837. 

2 Op. cit., p. 229. 



478 DESCRIPTION AND TREATMENT OF INSANITY. 

terotis to be met with in the whole range of psychological 
medicine, though, perhaps, in the earliest periods they may 
be not much more than suspicions or fears. Accepted not 
altogether with a certainty of their truth, they become more 
positive and abnormal as the disease advances, till eventually 
they reach the point of absolute impossibility of realization. 

Thus it is related of Falret, 1 one of the most distinguished 
alienists that France has produced, that, while he was a pupil 
of medicine at Montpellier, he was present at a lecture on 
phthisis. Such was the impression produced upon him by 
the graphic description of the disease that he thought for a 
long time that he was affected, and was only relieved of his 
apprehensions by ridicule and more thorough knowledge. 

Philip V, King of Spain, was constantly worried about 
his health. He was sometimes six months without leaving 
his bed. He would wear no shirts that had not been pre- 
viously worn by the Queen, fearful that any others would 
poison him. He occasionally believed himself to be dead, 
and expressed astonishment that he was not buried. His in- 
sanity was so marked that he bit and scratched his wife, his 
confessor, and his physician. 3 

Joseph Frank speaks of a man in Vienna who only chewed 
his food, swallowing nothing but the juice. The residue he 
kept, and submitted it to his physician for examination. He 
mentions another who went every week to his physician, sev- 
eral miles distant, with vases full of the faeces he had passed ; 
and a third, who, thinking himself affected with a liver dis- 
ease, applied his tongue to his excrements in order to ascer- 
tain whether or not they were bitter. In this connection I 
may state that a patient of my own affected with hypochon- 
driacal mania, and believing that the coats of his intestines 
were being expelled with his faeces, sent me once a large pack- 
age of the paper he had used for several weeks in the water- 
closet, in order that I might examine it microscopically. 

Louyer-Villermay 3 refers to the case of a man suffering 
from hypochondria who had a room in his house specially 
used to store the vases in which he kept his urine. He had a 
vase for each day in the week, and spent most of his time in 
their examination. 

1 Cited by Delasiauve in Journal de medecine mentale, t. v, 1865, p. 225. 

2 " Memoires secrets," de Duclos, cited by Delasiauve, op. cit., p. 226. 

8 Art. " Hypochondrie " in Dictionnaire des sciences medicates, t. xxiii, p. 127. 



HYPOCHONDRIACAL MANIA, OR MELANCHOLIA. 479 

A young man, having read several medical books, con- 
tracted the delusion that his head was filled with water and 
pus, and insisted upon its being opened in order that the fluid 
might be evacuated and his life saved. 1 

"George Woods, from Lower Lincolnshire, was admitted 
in Bethlehem Hospital November 25, 1819. This unfortunate 
young man had been professionally brought up a surgeon, 
and the cause of his malady appeared to have been the per- 
suasion that he had undergone the fate of Abelard, and this 
notion was the constant source of his lamentation ; for his 
perpetual complaint was, ' Oh, what shall I do ? what shall I 

do ? They have taken away my ! Gone, all gone ! What 

shall I do % All gone ! gone forever ! ' Convinced of this pri- 
vation, he imagined the loss had caused a contraction of his 
limbs ; and under this idea he had acquired habits of contrac- 
tion extremely painful to himself and distressing to all who 
saw him. His elbows were pressed in as if screwed to his 
sides, his lower arms projecting outward on a line with his 
chest, and his hands continually clenched with such power 
that they could only be opened by force for the purpose of 
washing them ; and then the palms were found to be so in- 
dented by the pressure of his finger-ends that they seemed 
almost to have grown together. But no sooner was he freed 
from restraint than they returned to their former position. 
He walked invariably on tiptoe, took very little exercise, and 
would stand for hours together in one spot without setting his 
heels to the ground, if not roused by the keepers and urged 
to walk about. At times he was without appetite, and very 
weakly ; at other times his appetite was good, and he would 
sit down contentedly to dinner without any appearance of 
pain. But, as soon as he had finished his meal, he got up to 
the gallery and began his usual plaints : ' Gone ! gone ! all 
gone ! What shall I do for my % ? 

"In May, 1820, a party of ladies of rank and distinction 
came to visit the hospital, and poor Woods was bewailing in 

his usual vein. ' Oh, my ! What shall I do for my ? 

They are all gone.' Then one of the ladies, a peeress, asked 
him what he complained of, but could get no reply but, ' Oh, 
my ! What shall I do for my ? Gone ! gone ! for- 
ever ! ' and this with a piteous look of tribulation. 

1 Michea, " Du siege, de la nature intime, etc., de l'hypochondrie," Mem. de 
Vacad. royale de medecine, t. x, 1843, p. 573. 



4S0 DESCRIPTION AND TREATMENT OF INSANITY. 

"The lady, unable to comprehend his meaning, applied 
for explanation to a keeper, who with some discreet presence 
of mind told her ladyship that the poor patient was in the 
habit of collecting a quantity of pebbles, flints, and other 
rubbish about the airing-ground, which he fancied to be emer- 
alds, rubies, diamonds, and other precious gems ; that it be- 
came necessary to take them away from him in order to pre- 
vent the accumulation of rubbish in the gallery ; and that a 
recent privation of this sort was now the subject of his lament. 
' Oh, poor man ! ' said her ladyship, turning to the patient, 
' never mind them. When his lordship comes here again he 
shall bring you some pretty ones which he has at home ; they 
will be much handsomer than those you have lost, so don't 
fret about them any more.' But poor Woods, not at all satis- 
lied with the promised alternative, answered, with much dis- 
pleasure, ' That won't do ! I will have none other but my 
own.' And thus they separated, each unconscious of the 
other's meaning." * 

Probably next after false perceptions and delusions con- 
nected with the digestive system, those with the genito-uri- 
nary organs, similar to the case just quoted, are most numerous. 
A patient of my own, after great sexual excesses, took the 
idea that his penis and testicles were diminishing in size. He 
spent the greater part of each day in measuring them, and in 
recording the results in a book which he kept for the pur- 
pose. Finally he reached the conclusion that they had entirely 
disappeared, and, although he did not go about lamenting 
the fact, he was examining the region as often as he could get 
the opportunity, and making a record of the results of his 
examinations. As an interesting instance of the line of 
thought of a hypochondriacal maniac, I transcribe here a por- 
tion of his diary for one day : 

" November 4th, 9 a. m. The event that I have been fearing 
has at length occurred. They have vanished, absolutely van- 
ished, and I am ruined ! Oh, my God, how I am punished 
for my sins ! 

"9.30 a. m. Cold water does no good ; hot water is no bet- 
ter. Will try blistering. 

" 9.45 A. m. There is not even a vestige of either penis or 
testicles, not a vestige. I will consult a physician. ~No, I 
cannot exhibit my misfortune. Applied blister. 

1 " Sketches in Bedlam," by A Constant Observer, London, 1823, p. 113. 



HYPOCHONDKIACAL MANIA, OR MELANCHOLIA. 481 

" 10 a. m. Removed blister to see if they really had gone. 
Alas ! it is too true. Blistering can be of no possible service. 
Removed it. 

" 10.15 A. m. Reflected that if they are really gone there 
ought to be something left to show where they had been. Find 
ample evidence. A vast cavity at the bottom of my belly. 
Will consult a surgeon ; but how in heaven can he help me ? 
Is there any medicine that can restore the organs when they 
have entirely gone, as have mine % It would be a mockery — 
a sinful mockery ; and God knows I have sinned enough. 

" 10.25 a. m. There is no doubt of it ! They have gone, and 
I am a ruined man ! Man ! I am no man. I am a eunuch ; 
an unsexed man ; a mere thing without purpose on the earth. 

"11a. m. I might sing in a choir if they are really gone ; 
but, O God ! for me, a man — a strong, lusty, vigorous, boast- 
ful man — to be reduced to singing in a church choir ! It is 
horrible ; but what else am I fit for ? My mind is certain to 
become weaker. I shall grow to be fat and pulpy. I will be 
an oyster — a big, disgusting oyster. 

" 11.10 A. m. Have just urinated, and had the most singular 
experience. The urine oozed out from the place where the 
penis used to be, but, alas, where it no longer is ! " 

This will suffice. There were hundreds of pages of such 
stuff. He finally came to see me, and brought his diary with 
him for my information. He, with the utmost confidence in 
the correctness of his perceptions and judgment, attempted 
to demonstrate to me the complete absence of his penis and 
testicles. I could detect no deviation from the normal stand- 
ard in either, but no arguments or tests that I could apply 
sufficed to undeceive him. He groaned and wept over his 
misfortunes, and walked up and down the room, cursing him- 
self for his wickedness, and the science of medicine for its 
inability to aid him. 

In another case the patient, a young lady, who had just 
left a school where her mental energies had been severely 
taxed, began to be troubled with insomnia and gastric and 
intestinal derangement. Her menstrual function, which had 
previously been normal, stopped altogether. One day she 
read in a newspaper an account of a so-called mysterious dis- 
ease which had affected the people of a Western town, the 
chief symptom of which was a gradual blackening of the 
tongue. She talked about the matter for several days, and 

31 



482 DESCRIPTION AND TREATMENT OF INSANITY. 

expressed so much interest in the subject that her friends 
laughed at her, and one of them said, laughingly, "One 
would think you were afraid you will get this black-tongue 
disease." From that time on her anxiety increased. She 
not only talked about the disease in a general way, but she 
applied to herself the little information she had obtained 
on the subject, and was sure that the first symptoms were 
already present. She spent the greater part of each day in 
examining her tongue before a looking-glass, which she kept 
constantly about her. If anybody looked at her she at once 
conceived the idea that her tongue was the object of inspec- 
tion. If two persons spoke together in her presence, she was 
certain they were talking of her. Finally, she was fully con- 
vinced that her tongue was really black, and that ere long 
it would drop off. No arguments, no appeals to her percep- 
tions or intellect, had the least effect on this illusion and 
delusion. Her emotional system was even more disturbed. 
She wept almost constantly, and in piteous language spoke 
of the great misfortune to which she was subjected. " What 
have I done," she said to me, "that I should be made to suffer 
in this cruel way? I have tried to be good, and yet I am 
treated like a criminal. I would rather have my tongue 
taken out with red-hot pincers than see it, little by little, 
mortifying in this way. It might be a proper punishment 
for a slanderer, but I have never slandered any one." 

I took a piece of very black paper, and held it by the side 
of her protruded tongue while she looked at both in the glass. 
"Yes!" she exclaimed, "my tongue is exactly like that; 
just as black, but shrivelled." 

I found that tactile sensibility in the tongue, though not 
abolished, was greatly diminished. The points of the sesthesi- 
ometer could not be discriminated at a less distance than 
seven twelfths of an inch, instead of the twenty-fourth of an 
inch, the normal distance. The ability to feel pain did not 
appear to be sensibly impaired. 

In the course of about two weeks I saw this patient again. 
She then conducted all communications with others by signs 
and by writing. Her tongue, she said, had dropped off. She 
had not seen it drop. It had disappeared in the night, during 
sleep, and she supposed she had swallowed it. In fact, she 
had, she declared, tasted something rotten in her mouth all 
the next day. She opened her mouth at my request, but 



HYPOCHONDRIACAL MANIA, OR MELANCHOLIA. 483 

when I asked her to put out her tongue she wrote, " How can 
I put out my tongue when I have no tongue % " When re- 
quested to open her mouth she did so, and when I pointed to 
her tongue and put my finger on it, and asked her what that 
was if it was not her tongue, she wrote, "It may look like a 
tongue to you, but it does not to me ; it is simply the base of 
my mouth. The membrane there is very loose." When I 
asserted positively that it was her tongue, she wrote, "I am 
the best judge on that subject. I came here to see if a new 
tongue could be transplanted from some one else. I am will- 
ing to pay largely any woman who will sell me her tongue." 
I suggested an animal's tongue — that of a sheep, for instance. 
She quickly wrote, "I could not talk with a sheep's tongue. 
I should have to say ' ba, ba, ba ' all my life. I would rather 
be mute." 

I was considering the propriety of performing, with the 
consent of her friends, a piously fictitious operation on this 
patient, for the purpose of acting on her mind, when I deter- 
mined first to treat her with aloetic purges, as recommended 
by Schroeder van der Kolk — a method that will be fully dis- 
cussed under the head of "treatment." The effect was entirely 
satisfactory. Large quantities of hardened fecal matter were 
discharged, the menstrual function was restored, and, before 
thirty days had elapsed, she was entirely free from all percep- 
tional, intellectual, or emotional derangement. 

The late Colonel Charles May, of the United States Army, 
informed me that he had cured a brother officer of a delu- 
sion by a well-intentioned deception. The gentleman had the 
belief that he had swallowed a chicken-bone, which had stuck 
in his throat before reaching his stomach. He went about 
with his hands pressed over the place where he supposed the 
bone to be, refused to eat any but liquid food, and complained 
of a constant pain in the part. Examination by the medical 
officer, and exploration with a probang, settled the point 
definitely that there was no bone there. But the patient was 
not convinced ; he felt it, and he knew it was sticking in his 
throat. 

Colonel May then suggested to the doctor that an emetic 
should be given, and, while it was acting, he dropped a chicken- 
bone, unperceived by the patient, into the basin. The latter 
examined the vomited matter very carefully, found the bone, 
and, triumphantly exhibiting it as positive evidence of the 



4S± DESCRIPTION" AND TREATMENT OF INSANITY. 

correctness of his sensations and his idea, was at the same 
time permanently cured of his delusion. 

The delirium of negation {delire des negations), as it is 
called by Cotard/is only a variety of hypochondriacal mania. 
In it the patients think they have lost various parts of their 
bodies ; their arms, legs, nose, eyes, head, stomach, womb, 
etc., have, they imagine, disappeared. I have already cited 
cases of this phase of the disease, but many others are on 
record still more pronounced. Indeed, it is by no means an 
uncommon manifestation of the affection in question. 

There are many other categories of delusions exhibited by 
hypochondriacal maniacs. Thus, there is a delirium of little- 
ness (delire micromaniaque\ in which the patients imagine 
that parts of their bodies have become reduced in size, or that 
the whole body has become smaller. A patient observed by 
Materne 2 desired to sleep in a cradle, "his legs being so small 
and his feet so narrow that he dared not sit up even for an 
instant." 

The opposite condition may exist, in which there are illu- 
sions and delusions that things are larger than they really 
are. One man, for instance, conceived that he had grown to 
such an enormous size that he could not pass through a 
doorway, though in reality he was very thin. He apparently 
suffered the most exquisite torments, when some persons, 
thinking to cure him in that way of his delusion, dragged 
him forcibly through a doorway. 

A gentleman, who came under my observation, had the de- 
lusion that his head was of enormous size. It was as large, 
he said, as a half -bushel measure, and was constantly grow- 
ing larger. He insisted that no hat would fit him, and that 
the disease and exposure would soon end his life. The delu- 
sion had been excited by several friends, who, by way of a 
joke, conspired to tell him, when they saw him in town, that 
his head was growing bigger. At first he laughed at the 
idea, but one of them surreptitiously changed his hat for 
another much smaller, and that convinced him. He became 
terribly frightened, went home with the delusion firmly 
established, and was soon afterward, I believe, sent to a 
lunatic asylum. 

1 " Du delire des negations," Archives de neurologie, No. 11, 1882, p. 152 et 
seq. 

2 These de Paris, 1874, obs. vii. 



HYSTEKICAL MANIA. 485 

This form, which has received little notice from alienists, 
might properly be designated macromaniacal delirium. 

Again, there are sensations of things of various kinds in 
the stomach and intestines, or the chest or brain. One pa- 
tient believes that there is a galvanic battery in his stomach, 
by means of which all his nerves and muscles are kept in a 
state of perpetual excitement. Another has the delusion that 
a steam engine is in his heart, and that boiling blood is 
being pumped to every part of his body. Another imagines 
that her womb' contains every day a new foetus, which is born 
in the night and carried away by her enemies. Another 
thinks his brain consists of snakes, which" are constantly 
writhing and twisting within his skull ; and others have 
demons, and fairies, and elfs, and giants located in various 
parts of their bodies, and annoying them with their jibes, 
curses, and commands. There is no end to the fancies of this 
kind, and they seem to be among the most persistent of all 
the delusions which the hypochondriacal maniac can enter- 
tain. It is probable that they are in the first place excited by 
various abnormal and real sensations, and that the peculiar 
character of the delusion in any one case is due to accident, 
or to the reading of stories of various kinds. 

Hypochondriacal mania is not characterized by intermis- 
sions or by any marked remissions. There are times, as in all 
forms of insanity, in which the patient is more or less free 
from delirium, and does not obtrude his delusions on those 
around him, but questioning will show that they are still 
present, and that he is thinking of them with all the force of 
his mind. 

The affection is much more common in men than in women, 
and in persons between the ages of twenty -five and forty than 
at other periods. Women are more apt to become the sub- 
jects at or about the menopause. It is one of the most obsti- 
nate of all the forms of mental derangement, though not by 
any means beyond the reach of remedial agents, unless it has, 
by lasting many years, become an integral part of the patient's 
mentality. In such a case a cure is not to be expected. 

g — HYSTERICAL MA]STIA. 

Hysterical mania has been considered by some authors as 
the analogue in the female of hypochondriacal mania in the 
male. The differences between the two affections are, how- 



486 DESCRIPTION AND TREATMENT OF INSANITY. 

ever, so many and so great as not to warrant an assumption 
of their identity. Hypochondriacal mania is met with in 
women, and hysterical mania is sometimes seen in men. 
Moreover, in hysterical mania the delusions, though some- 
times relating to the individual herself, differ altogether in 
character from those peculiar to hypochondriacal mania. The 
emotional disturbance has scarcely any affinities with that 
present in the latter disease, and it exhibits other phenomena, 
to which attention will be called, which hypochondriacal 
mania never presents. As hypochondria is hot hypochon- 
driacal mania, so hysteria is not hysterical mania. It may 
be, however, and often is, as in the former case, the patho- 
logical basis on which the mental aberration rests. 

The disorder may arise suddenly, without any previous 
obvious symptoms, or, as is generally the case, it may be 
preceded by well-marked prodromata. These consist of the 
phenomena indicative of the hysterical diathesis, and have 
been well set forth by Georget. 1 

" Almost all these patients," he says, "are endowed with 
great physical activity. They are impressionable, possess a 
vivid imagination, are disturbed every instant of their lives, 
and by the most trivial causes ; they are quick, impatient, 
irascible, self-willed, obstinate. .Some exhibit great sensorial 
acuteness and irritability. The eyes cannot support a strong 
light ; they hear the slightest sounds, and perceive the faint- 
est odors. The least degree of cold or heat pains them, and 
a highly electric condition of the atmosphere is particularly 
unpleasant to them. Their sleep is rarely sound or continu- 
ous, and is often disturbed by painful dreams. Some are 
taciturn and disposed to court solitude ; others, on the con- 
trary, affect a gayety which is forced and unnatural. They 
laugh upon the slightest motive, and often without any appar- 
ent cause ; others laugh and weep by turns without knowing 
why." 

In addition, they suffer from headache, vertigo, and gas- 
tric and intestinal derangement. It may be, also, that they 
have experienced one or more pronounced hysterical attacks 
in their varied forms. 

One of the most striking characteristics of hysterical mania 
is the complete perversion of the emotions which it exhibits. 
A young girl, for instance, brought up in the midst of the 

1 " De la phjsiologie du systeme nerveux," etc., Paris, 1821, t. ii, p. 270. 



HYSTERICAL MANIA. 487 

most refined and moral influences, suddenly or gradually ex- 
hibits a coarseness of manner and of language, and an immo- 
rality of ideas, shocking to all with whom she is in association. 
In the discussions which may take place in the family she 
defends the most atrocious criminals, and this in words never 
heard in polite society. Indeed, it is often a matter of aston- 
ishment where she could have obtained a knowledge of such 
expressions as she employs. If remonstrated with, she ex- 
presses her dislike, even hatred, of those who reprove her, be 
they ever so near relatives, and threatens to leave the house, 
and probably makes several attempts to escape from what 
she calls her jail and her jailers. A case reported by Chairau l 
is instructive in this relation : 

" Mademoiselle B., aged twenty-eight years, of a decidedly 
lymphatic temperament, menstruated late, and always irregu- 
ularly, and with pain. She had received a good education, 
and was very intelligent. When she was twenty-two years 
old her father's house was frequently visited by a young 
man to whom she became attached, and she persuaded her- 
self that he was about to make a proposal of marriage. She 
spoke to her father on the subject, who said that, while he 
had no objection to the gentleman, there was nothing in his 
conduct to warrant the supposition that he contemplated mar- 
riage. He consequently insisted that his daughter should 
cease to concern herself with the matter. Several weeks after- 
ward, the young man obtained a lucrative position in a for- 
eign country, and left France without having shown the 
slightest desire to marry the lady. From this time Made- 
moiselle B. became depressed in mind. She ceased to oc- 
cupy herself with those things which had given her pleas- 
ure, and shut herself up in her room. Her mental faculties, 
especially her memory, became weak, her appetite was lost, 
her menstruation became more irregular and painful, and 
attacks of hysteria were provoked on the least contradiction 
or obstruction of her wishes. At the same time, her digestion 
was deranged, she experienced sharp, epigastric pains, and 
her body was covered with acne. She began to be emaciated, 
and anaesthetic and hypersesthetic zones appeared on various 
parts of her body. 

"The moral faculties were altered in a marked degree, and 
she formed a fixed idea of running away. It was necessary 
lu Etudes cliniques sur l'hysterie," etc., Paris, 1870, p. 57. 



4SS DESCRIPTION AND TREATMENT OF INSANITY. 

to bar the windows, to lock the doors, and to have an attend- 
ant constantly with her. She would have nothing to do with 
any member- of her family. As she had persuaded herself 
that her clothes somehow or other were aids to her imprison- 
ment, she was forever endeavoring to strip them off. If she 
was left for a few minutes alone in her room, she was found 
naked when the attendant returned. One day she was left 
for a short time alone in the garden. She profited by the cir- 
cumstance to lock herself in the cabinet d'aisance. Neither 
prayers nor threats could induce her to come out. At last a 
mason was sent for to cut a hole in the wall. She was found 
entirely naked, and her clothes she had thrown down the hole. 

" The maniacal symptoms were increased at her menstrual 
periods to such a degree that she struck furiously all those 
who attempted to arrest her in her movements toward flight." 

But, as Legrand du Saulle ' remarks, hysterical mania may 
make its appearance either as acute mania, melancholia, hal- 
lucinations, or irresistible impulses. Generally all these 
forms are combined. But with all these there is usually the 
distinguishing features to which I have alluded — the radical 
change in the character, mode of thought, expressions, and 
conduct of the subject, and this without apparent motive ; 
solely, as it were, from a suddenly developed spirit of wicked- 
ness. It is no matter for astonishment, therefore, that in a 
period of the world's history when devils and demons were 
universally believed to exist, as they still are by ignorant or 
superstitious people, the idea that they could enter the system 
and misdirect the mind and body of an individual, should 
have existed. Holy women, saints and nuns, would all at 
once exhibit the most diabolical characteristics, and, influ- 
enced by the belief that existed, would proclaim aloud that 
the devil or some of his imps had taken possession of their 
bodies. The form of insanity has not changed since then ; 
we merely explain it on a different hypothesis. Under the 
head of "epidemic insanity" this point will be more fully 
considered. 

Morel, 3 in speaking of the spontaneity of hysterical mania, 
cites the following cases : 

A young hysterical girl was dining with her parents. She 
left the table, and, her prolonged absence having alarmed the 

1 " Les hysteriques ; etat physique et 6tat mental," etc., Paris, 1883, p. 293. 
3 " Traite des maladies mentales," Paris, 1860, p. 676 {note). 



HYSTERICAL MANIA. 489 

family, search was made for her. She was found in a neigh- 
boring wood, occupied in gathering stones with which to 
make an altar, before which she was going to be married. 
She was crowned with flowers, and had taken off all her 
clothes. Another left the arm of her father during a village 
fete, and threw herself into a stream of muddy water. In 
another case he diagnosticated the existence of hysterical 
mania in the case of a lady, twenty-four years of age, who was 
often seized with paroxysms, during which she would violently 
throw down any piece of work upon which she was engaged, 
rise from her chair, and break the glass or plates that might 
be in the room. One day she got up from the table, and, seiz- 
ing a vessel of boiling water, emptied it, without the slightest 
manifestation of feeling, over the neck of her brother. 

In the following case, also quoted from Morel, there was 
hereditary tendency to mental derangement, and the existence 
of the hysterical type of organization in a marked degree : 

The young Eliza C, born of an intelligent mother, but 
whose father was of limited intellect and neurotic tempera- 
ment, menstruated when twelve years old. Her disposition 
was always sullen, capricious, and eccentric, and she never 
exhibited the least feeling of tenderness toward either of her 
parents. She laughed and cried without cause, and commit- 
ted, from an early period of her life, all kinds of singular and 
ridiculous acts. Placed among other girls to learn the trade 
of a seamstress, she could not be prevented from using inso- 
lent and obscene language. Soon she exhibited a series of 
spontaneous and delirious acts such as are met with in hys- 
terical mania. One day, for instance, she crowned herself 
with flowers, took a guitar, and announced that she was going 
to travel through the world. She got up in the night and 
washed her clothes in the chamber-pot. Then she had convul- 
sive seizures, mewed like a cat, tried to climb up the wall, was 
violent in her acts toward others, and finally fell into a state 
of stupor. These accessions were periodical, and it became 
necessary to send her to an asylum. 

Though the conduct and language may often give evidence 
of the existence of erotic ideas, or even of the presence of 
nymphomania, it is rarely the case that there is any real ex- 
altation of the sexual appetite. The acts and words in ques- 
tion appear rather to be the expression of a spirit of con- 
trariety — a disposition to do something that will astonish or 



490 DESCRIPTION AND TREATMENT OF INSANITY. 

sliock the friends — than of any actual desire for sexual inter- 
course. Indeed, women affected with hysterical mania have, 
upon several occasions, with great glee, while in a state of 
apparent libidinous excitement, informed me that they wanted 
to annoy such or such a member of the family. " You think 
that is bad % " said a girl who was suffering from a violent par- 
oxysm of hysterical mania to her mother, who was shocked 
at some obscene words she had spoken; "well, what do you 
think of this?" and then she gave utterance to a series of 
ideas of so obscene a character, and in language so vile, that 
her poor mother rushed in despair and horror from the room. 
"I thought that would astonish the old lady," said the pa- 
tient, with great satisfaction, "but that is nothing to what I 
could do if I really tried. Now bring me my Bible, for I 
want to read a chapter and say my prayers." 

MM. Charcot, 1 Bourneville and Eegnard, 2 Richer, 3 and 
others, have studied with great care certain manifestations 
of hysterical mania which had been noticed, with more or 
less thoroughness, by Brachet, 4 Dubois, 6 Landouzy, 6 Briquet, 7 
Brigham, 8 and other writers, and by physicians generally. 
Into the full consideration of this variety of hysterical mania 
I do not propose to enter at present. A short description of 
it, and the citation of a case or two, will suffice to place the 
chief features of it before the reader. 

In the beginning there is usually an epileptoid seizure, dif- 
fering in no essential respect from a paroxysm of the grand 
mal, as ordinarily observed. This is succeeded, after a period 
of repose, by the "period of contortions and of great move- 
ments (clonism)." 9 It embraces two phases — that of illogical 
attitudes, or contortions, and that of great movements. Both 
of these categories require a suppleness of body and agility, 

1 " Lecons sur les maladies du systeme nerveux," Paris, 1876. 

2 " Iconographie photographique de la Salpetri&re," Paris, 1876, 1877. 

3 "Etudes cliniques sur l'hyste>o-epilepsie," Paris, 1881. 

4 " Recherches sur la nature et le siege de l'hysterie et de l'hypocondrie," 
Paris, 1832; also, "Traite de l'hysterie," Paris, 1847. 

5 "Histoire philosophique de l'hypocondrie et de l'hysterie," Paris, 1837. 

6 " Traite" complet de l'hysterie," Paris, 1846. 

7 "Trait6 clinique et therapeutique de l'hysterie," Paris, 1859. 

8 " Observations on the Influence of Religion upon the Health and Physical 
Welfare of Mankind," Boston, 1835. 

9 In this description, I have abbreviated the very full account given by Richer 
in the work to which reference has been made. 



HYSTERICAL MANIA. 491 

and a muscular force well calculated to astonish the spectator, 
such as, at the time of the convulsionnaires of St. Medard, 
appeared to be above the resources of nature, and only to be 
explained on the hypothesis of divine intervention. Thus, the 
body may be bent into the form of a bow, more or less deeply 
arched, the heels and the head only touching the bed — a true 
opisthotonos being produced ; or the limbs may be twisted 
into all kinds of fantastic attitudes, and the most remarkable 
flexions and extensions and leaps ensue, and cries of rage or 
fright are uttered. Then follows the third period, during 
which there are what M. Charcot has designated " passion- 
ate attitudes" (attitudes passionelles), in harmony with the 
hallucinations with which the subject is affected. She is, in 
fact, the prey of the false perceptions which govern her and 
carry her into an imaginary world. The expression of her 
countenance, as well as the motions of her body and limbs, 
reveals what is passing in her mind, and the words she utters 
still more forcibly express her thoughts. When the par- 
oxysm has passed off, she remembers perfectly well all that 
has occurred and all she has experienced. 

During this period of hallucinations the patient is entirely 
insensible to all external irritation. Pinching, pricking, 
touching the conjunctiva, the application of a bandage over 
the eyes, the inhalation of ammonia, loud noises near the 
ears, and other ordinary excitants, fail to interrupt the course 
of her delirium. There are only two means of stopping the 
paroxysm and restoring the patient to her senses. One of 
these is the excitation of the hystogenetic zones, and espe- 
cially compression of the ovary, of which the effect is invari- 
able and immediate ; and the electric shock, which, without 
being always as prompt and as certain as the other, is, never- 
theless, sufficiently evident. 

Two phases of hallucinations are exhibited during the seiz- 
ure, the sad and the gay ; and these alternate, without inter- 
ruption, during its continuance. 

The following is one of the shortest of the cases reported 
by M. Eicher, and will serve, though not one of the most 
striking, as a good example of the affection : 

Juliette Dub., eighteen years old, tall, strong, and of good 
constitution, entered the Salpetriere, in the service of M. 
Charcot, March 29, 1879. With the exception of an attack 
of typhoid fever when eleven years of age, Juliette enjoyed 



492 DESCRIPTION AND TREATMENT OF INSANITY. 

good health till her fifteenth year. At this time she had a 
paroxysm of epilepsy, and then others up to the time of her 
entering the hospital. 

Six weeks after her arrival it was noticed that she had 
attacks of grand hysteria (hystero epilepsy). In addition to 
the more common symptoms, she was hemi-ansesthetic and 
achromatopic on the left side. Besides the ovarian hyper- 
esthesia, she had the other hystogenetic zones — one over 
the vertebral column, between the shoulders, and one on each 
side of the sternum. Pressure over either ovary or over either 
of the other spots was sufficient to develop a paroxysm. 

She exhibited the ordinary prodromatic signs of an attack 
— agitation, perversion of ideas and of feelings, ovarian pain, 
especially on the left side, thoracic pain below the breasts and 
on a line with the hystogenetic zones, a sensation of strang- 
ling, throbbings in the temples, and noises in the ears, prin- 
cipally on the left side. It was a noticeable fact that at the 
moment the convulsions were about to occur her sight became 
red. 

On the 26th of September she had several attacks. 

I. (a) At 10.36, epileptoid period, marked by rigidity of the 
whole body in extension, followed very soon by a general and 
violent trembling. 

(&) The second period was characterized by five rapid and 
extreme " salutations," by irregular leaps or jumpings, aloud, 
prolonged cry, then the "arc of a circle," the patient resting 
on her side. 

(c) The third period followed immediately ; was composed 
of passionate attitudes,* varied with hallucinations, in the fol- 
lowing order : Attitude of menace, wild expression ; expres- 
sion calmer ; the patient puts a finger over her mouth, catches 
herself by the throat, and rolls about the bed as if suffocating. 
The face is congested. Another attitude of menace. Terror 
calmer ; appears to be preoccupied with a vision above and in 
front of her bed ; looks to the right and left, and changes her 
physiognomy every instant. 

II. (a) At 10.40, another epileptoid period similar to the 
preceding. 

(b) Several leaps; attitude of "arc of circle," with the 
concavity in front; the "arc of circle," with the concavity 
behind. 

(c) Seated on her bed, the patient seems to question with 



HYSTERICAL MANIA. 493 

her expression an invisible person, the fingers of the right 
hand being pressed to her lips. Suddenly terror ; attitude of 
defence, the elbow raised as if to ward off a blow, while her 
face assumes a furious look. Looks around her bed, touches 
it with her hand, lies down again, feels her pillow. Her eyes 
are again directed above ; gesture of defiance. Bites her fin- 
gers ; makes a sign with the hand as if to repulse some one. 

III. (a) Suddenly her head is turned to the right. Body 
extended and rigid ; then trembling. 

(b) Five great leaps ; cries varied ; "arc of circle" anterior, 
posterior, lateral. 

(c) At 10.48, movement of defence, look of defiance ; crosses 
her arms, and seems to question some one. Pleasant vision 
above and to the left ; makes signs of negation. Looks to the 
left on her bed, embraces her pillow, laughs, caresses it, em- 
braces it again ; attitude of terror, her look being directed 
above and to the right. 

This is the record of three attacks. They are mild com- 
pared to others detailed in the same work, and in that of MM. 
Bourneville and Regnard. 1 

Though this form of hysterical mania is comparatively rare 
and of mild form in this country, several cases have come 
under my observation. 3 The following is of recent occurrence : 

A young lady from a Western city was brought to me in 
the winter of 1881-82. She had had repeated convulsive 
seizures, attended by delirium, which, from the description 
given, were easily recognizable as being attacks of hystero- 
epilepsy. I had the opportunity of seeing her in several of 
these at her hotel. 

First, there was an epileptoid paroxysm, during which the 
body was rigid, the face purple, the respiration suspended. 
This was immediately followed by clonic convulsive move- 
ments lasting only about half a minute, and during which the 
patient foamed at the mouth. 

Then ensued a state of opisthotonos, the head and heels 
only touching the bed, and this was followed by relaxation 
and various movements of an indeterminate character, and 
somewhat cataleptoid in appearance. 

This stage was succeeded by another in which she became 

1 " Iconographie photographique de la Salpetriere," Paris, 1876-'77. 

2 " A Treatise on the Diseases of the Nervous System," seventh edition, New- 
York, 1881, p. 786, art. " Hystero-Epilepsy." 



49i DESCRIPTION AND TREATMENT OF INSANITY. 

delirious and exhibited numerous passionate facial expres- 
sions and movements. At one time she leaped from her bed, 
rushed to the window, and would apparently have jumped 
out had she not been arrested. Then she struggled violently, 
at the same time crying out: "You shall not! I will not 
allow it ! No, no ! Oh, why is it so ! Keep off, I say ! Do 
you want me to kill you ? Take him away ; take him away ! " 
Then, suddenly changing her demeanor and expression to one 
of intense pleasure, she went back quietly to bed, and soon 
fell asleep. 

When she awoke, she had entire consciousness of all that 
took place after the epileptoid seizure. She said she had im- 
agined that when she leaped from the bed some men were 
attacking her father in the court- yard below, and that he had 
called to her for help ; that then the men had attacked her 
and had offered her various indignities, which she did not 
specify, but the character of which may readily be inferred ; 
that finally some friends had come to her relief. 

In one of her paroxysms she grasped a large knife that lay 
on the table, and would have killed her mother with it had 
she not been seized by her sister, who was present. She ex- 
plained this subsequently by saying that she had thought her 
mother was a black man who was stealing her jewelry. 1 

In most cases of hysterical mania, hallucinations, especially 
of sight and hearing, are present. Generally those of sight 
relate to animals of various kinds, usually of such as are 
frightful. Thus, black pigs, serpents, lions, tigers, elephants, 
rats, and horrible bugs and birds are common spectra. Oc- 
casionally, but not so frequently as in a former period, devils, 
witches, sorcerers, etc., make their appearance. Angels and 
beautiful men with white flowing hair and rosy complexion 
are not infrequent. Hallucinations of hearing are generally 
of voices communicating pleasant or unpleasant information, 
or of music which is described as being "heavenly," or other- 
wise supernaturally melodious. 

The other senses are rarely perceptionally deranged. 

1 I do not enter here into the consideration of the hypnotic, cataleptic, som- 
nambulic, and other phenomena which hystero-epileptics sometimes exhibit. 
They are thoroughly discussed by M. Charcot and his pupils in the works to 
which reference has been made, and to some extent in a little book of my own, 
" On Certain Conditions of Nervous Derangement," New York, 1880. Some of 
them will be further considered in the remarks I shall have to make relative 
to epidemic insanity. 



HYSTERICAL MANIA. 495 

An important point connected with the manifestations of 
hysterical mania is the unreasonable and instinctive disposi- 
tion to deceive which the subjects exhibit. There seems to 
be with the majority of the patients affected with the disease 
in question an inveterate tendency to practice the most un- 
necessary and illogical frauds, and to tell the most barefaced 
and improbable lies, without any apparent object in view, or 
any purpose to subserve, unless it may be the satisfaction of 
the desire for notoriety, which is so powerful a factor in de- 
termining the conduct of these people. Perhaps, in some 
cases, there may be the foundation of an illusion or a hal- 
lucination accepted as a fact, but I have never observed in 
my own experience any evidence in support of such a sup- 
position. In the furtherance of these purposes of deception 
they often do not hesitate to accuse themselves and others of 
the most preposterous crimes. As Morel 1 says: " They en- 
velop themselves in the most whimsical, false, ridiculous, and 
unjust ideas. The love of truth being no longer a dominant 
feature of their character, they never relate events as they 
actually occur, and they deceive with equal pleasure their 
husbands, parents, confessors, and physicians." 

If they have any bodily disease, they exaggerate all the 
symptoms ; if they have none, they manufacture one for the 
purpose of deceiving their physicians, and show the utmost 
satisfaction when, through their lies and lamentations and 
expressions of fear, they have succeeded in their object. 
The distinguished French surgeon, Chomel, always avoided 
in his practice hysterical women, because he had often 
been deceived by them ; but he often told the following 
story : 

A patient entered his service presenting neurotic phe- 
nomena, the singularity and eccentricity of which strongly 
interested him. He examined her with the utmost care, took 
notes of the more important and remarkable symptoms, and 
remained over an hour studying her case. Then, when he 
could think of no more questions to put, he asked her if there 
was anything more she wished to say. " Yes, sir," she an- 
swered, "it is that there is not one word of truth in what I 
have told you." 2 

1 " Etudes cliniques sur les maladies mentales," Nancy, 18ol-'52. 

2 Quoted by M. Huchard, " Caractere, moeurs 6tat mental du hysteriques," 
Archives de neurologie, mars, avril, 1882, p. 194. 



49G DESCRIPTION AND TREATMENT OF INSANITY. 

Tonlmouclie J cites tlie case of a young girl, much given to 
devotional exercises, and subjecting herself to ascetic morti- 
fications and violent flagellations, who one day seized a pair 
of scissors, and made with them more than six hundred cuts 
over her whole body. Then she asserted that the wounds 
had been made by a man who had endeavored to violate her 
person. Interrogated sharply by M. Toulmouche, she ended 
by confessing that she had herself made the wounds, and 
that she had done so a short time before one of the attacks of 
hysteria to which she was subject. 

In 1873, says M. Hu chard, 2 Mile, de M., aged eighteen 
years, accused the vicar of the parish of having committed a 
rape upon her. She stated that on such a day and at such 
an hour, while she was saying her prayers in church, the 
vicar, after having shut all the doors, approached her and 
requested her to go with him into the sacristy. There he had 
made, she declared, indecent proposals to her, and, as she re- 
pelled him with indignation, he had pointed a dagger at her 
heart. She had fainted, and, when she recovered her senses, 
she discovered that she had been violated. During the trial 
of the accused priest the medical experts questioned her in 
regard to the modus faciendi, and, as she answered by giv- 
ing childish details, she was submitted to physical examina- 
tion, with the result of ascertaining that she was a virgin, and 
that there were no traces of violence. 

Tardieu, 8 in calling special attention, in its medico-legal re- 
lations, to this tendency on the part of hysterical maniacs to 
lie, and to make charges against others which have all the ap- 
pearance of being malicious, refers to a recent case, that of a 
young girl, an inmate of a convent in Gascony, who persuaded 
her father that she had been made the victim of all kinds of 
tortures and unheard-of outrages. He, believing what she 
said, went before the authorities and denounced the alleged 
perpetrators. Finding, however, that she had deceived him, 
not a word of her story being true, he took his life from cha- 
grin and mortification. 

In another case, a girl, by a lie of the same kind, had two 
young men imprisoned more than a year on the false charge, 

1 " Consultations medico-16gales sur deux cas assez rare d'aberration men- 
tale," Annates (Phygttne publique, etc., l re serie, t. i, p. 424, 1853. 

2 Op. cit., p. 196. 

3 " Etude m6dico-legale sur la folie," Paris, 1880, p. 174. 



HYSTEEICAL MANIA. 497 

as it afterward was proven, not only of having violated her 
person, but of having also, on many occasions, introduced into 
her rectum and vagina stones and pieces of wood and iron, 
that had to be extracted from her with great pain. At the 
end of the operation she had several convulsive seizures, fol- 
lowed by paralysis apparently of the whole body. She was 
taken into a hospital, in order that her case might be studied 
to better advantage. But there she again succeeded in coun- 
teracting the surveillance of which she was the object. In 
addition to the paralysis, she simulated a complete constipa- 
tion. She did this by concealing the discharged fecal matters 
in the mattress, where they were subsequently found. Event- 
ually her lies and frauds were exposed, and the two young 
men were released from their unjust confinement. 

Such cases as these are interesting in their medical rela- 
tions, and they are of vast importance in their bearings upon 
jurisprudence. Cases not infrequently occur in this country 
in which women laboring under hysterical mania falsely ac- 
cuse others of crimes, sometimes making so full and detailed 
a confession of their own participation as to give the utmost 
similitude of truth to the story, and to lead many to believe 
that, however false the recital may be, it is accepted as true by 
the narrator. As already said, I do not think they are ever 
deceived. On the contrary, I am quite sure that they are fully 
aware at every moment that they are lying, and that it is this 
tendency to falsehood and fraud which constitutes a promi- 
nent feature of the disease. The following case, though no 
accusation of crime was made, is similar in all essential re- 
spects to those cited, and is additionally interesting by reason 
of the fact that the patient confessed that she had attempted 
deception. 

Miss A. W., twenty-seven years old, unmarried, and in af- 
fluent circumstances, residing in a large Eastern city, accom- 
panied by her aunt, consulted me, April 14, 1878, for an affec- 
tion which she said was driving her mad. The most promi- 
nent symptoms were "nervousness," pain in the front of the 
head, inability to sleep, confusion of ideas, numbness of the 
arms and legs, tenderness over several parts of the spine, loss 
of appetite, dyspepsia, a fixed pain in the left groin, a constant 
gnawing sensation at the pit of the stomach, "like," as she 
said, "the pain that would be caused by some small animal 
biting and tearing me with its teeth," and, above all, by an ir- 

32 



49S DESCRIPTION AND TREATMENT OF INSANITY. 

resistible impulse to swallow pins and needles. Some eight 
months previously she had, as she informed me, accidentally 
swallowed a pin which, while dressing herself one afternoon, 
she had for a moment put between her lips. She thought 
very little of the circumstance at the time, and suffered no 
immediate inconvenience from it. In fact, it had passed out 
of her mind, till a few weeks afterward she had felt a sharp 
pain at a point on the inside of the left thigh, a little above 
the knee, and, on examination, had discovered the point of a 
pin protruding through the skin. With some little pain and 
trouble, she had extracted the foreign body, and then found it 
to be, to all appearance, the very pin she had swallowed. 

The next day another pin slipped down her throat in pre- 
cisely the same way as the other. She felt some pain in the 
region of the stomach very soon afterward, but experienced 
no other symptom from it till exactly one week subsequently 
she suffered a little smarting, just above the right knee, at a 
point corresponding to the place where the other pin had made 
its exit from the left thigh. On inspection, she discovered a 
sharp metallic body sticking out of the skin. She seized this 
with a pair of tweezers, and succeeded in removing a pin — 
doubtless, as she said, the identical one she had swallowed a 
week before. 

She now began to feel, as she declared, a desire to swallow 
pins, and, yielding to it, allowed two or three every day to go 
down her throat. These subsequently made their appearance 
in various parts of her body. She had extracted them from 
the arms, breast, the neck, various points of the back and 
abdomen, the thighs and legs, and even as far down as the 
feet. One had come out of the eyeball, two from the ears, 
a dozen or more from the vagina, a great many had been 
passed from the bowels, and several from the bladder. In 
all, she thought she had swallowed over two hundred and 
fifty pins, and a number were, at the time she consulted me, 
making their exit from her body at various points of the sur- 
face. 

She rather courted an examination than otherwise, and, on 
inspection, I discovered one pin protruding from the skin of 
the left forearm just below the elbow, another from the breast 
below the left mamma, another from the skin of the back on 
the right side, on a line with the first dorsal vertebra, two 
immediately below the umbilicus, and sixteen in the vagina. 



HYSTERICAL MANIA. 499 

I nrast say that I did not believe a single word of her 
story, and I was convinced, before examination, that all the 
pins that wonld be fonnd would be only those that she had 
previously stuck under the skin. As a matter of fact, all 
protruded by the heads, and not by the points. Those in the 
vagina were in a bundle, with the heads toward the exterior. 

Her chief object, she said, in consulting me was to be cured 
of her irresistible impulse to swallow pins and needles. I 
remarked to her that I had not found any needles, but she 
explained this by saying that she had that morning, before 
coming to me, taken out seven or eight, and that she had the 
previous morning swallowed as many as fifty, which would 
begin to make their appearance in the course of the week. 

I refrained from taxing her with the fraud at this time. 
I saw that she was strongly hysterical, and I wished to sub- 
ject her to medical treatment for a few days before accusing 
her of deception and thus losing her confidence. 

But I had an interview with her mother, a very sensible 
lady, and told her my conviction that her daughter was prac- 
ticing a deception for which she was not altogether respon- 
sible. She told me that no one had ever seen her daughter 
swallow either pins or needles, and at once agreed with me 
as to the falsity of the whole story. 

At the daughter's subsequent visit to me, November 17th, 
she was, at my request, accompanied by her mother. She was 
feeling much better in every respect, but the pin and needle 
swallowing, she declared, still continued, and many were at 
that time sticking out of her body. I removed fifty-two pins 
and needles from various parts, including ten pins from the 
vagina — all with the heads and eyes pointing outward. 

I then informed her that I was certain she had not swal- 
lowed a single pin or needle, and that all I had extracted had 
been previously put in the places where they had been found. 
She was at first very indignant, and pretended to be about to 
leave the room in a rage ; but in a few minutes, after I had 
reasoned with her and informed her that it was the impulse 
to deceive of which she had to be cured, and not of one to 
swallow pins and needles, she began to sob and cry, and ended 
by a full confession that the whole story to me and her subse- 
quent conduct were deceptions. 

In this case the prime motive for the fraud attempted to 
be practiced appeared to be the* desire to excite astonishment 



500 DESCRIPTION AND TREATMENT OF INSANITY. 

and sympathy, although the patient could give no very defi- 
nite account of the matter. She said that the idea of the de- 
ception had not occurred to her till after she had left her own 
house to visit me. She was inclined to think that the govern- 
ing incentive had been an idea that her real symptoms were 
not sufficiently striking to excite my interest, and that she 
would be more likely to obtain attention if she reported her- 
self to be the subject of some unusual disorder. She went on 
improving, and is now, I believe, in very good health. 

In another and still more interesting case, which has within 
a short time been under my care, the patient, a young lady 
of twenty years of age, carried on for several months a sys- 
tematic course of deception which not only greatly injured an 
excellent young man, but damaged her own character to such 
an extent that her family were obliged to move away from 
the place in which they were living. In this instance the 
patient, by wearing pads over the abdomen and gradually in- 
creasing their thickness, led to inquiries from her mother as 
to the cause ; and, suspicious that an abdominal tumor existed, 
it was decided to consult an eminent gynaecologist of a neigh- 
boring city, when the girl, with tears and lamentations and 
self-reproaches, confessed that she was pregnant. Of course, 
the distress in the family was very great, and a great deal of 
anger was exhibited toward the supposed miscreant who had 
ruined a virtuous woman. For a long time she refused to 
reveal the name of the seducer ; but finally one morning she 
came down stairs with a letter she had written to her father, 
and in which a full but false revelation of all the circum- 
stances was made. In this letter she declared that a gentle- 
man they all knew and respected was the seducer. 

Arrangements were made for her confinement in a distant 
city, and at the same time it was resolved to arrange, if pos- 
sible, a marriage with the alleged destroyer of their daughter's 
honor. The father, accordingly, had an interview, at which 
the gentleman was offered the alternative of an immediate 
marriage or instant death from a pistol pointed at his head. 
Denials and protestations were useless ; the father was obdu- 
rate, and the pistol, cocked, was very near his brain. He con- 
sented to the marriage, but only on the condition that he 
should at once be granted an interview with the lady in the 
presence of her parents. This was agreed to. A meeting 
took place at once, and the gentleman, who was a lawyer, 



HYSTERICAL MANIA. 501 

succeeded, by his tact and the directness of his questions, in 
exposing the fraud and obtaining a full confession. It is, 
perhaps, scarcely necessary to add that the marriage did not 
occur. 

As I have already said, the subjects of hysterical mania 
are not disposed to attempt suicide. Occasionally, however, 
a tendency in this direction is manifested, but it is often more 
apparent than real. It is an act of deception, like so many 
others perpetrated by hysterical maniacs. As Legrand du 
Saulle T says, when they attempt suicide they do not proceed 
as do other people : they try to hang themselves with the rose- 
colored ribbon of a box of bonbons, or they make a show of 
taking poison when others are present. In such instances 
they are generally actuated by a desire to accomplish some 
object they have in view, and which they think will be more 
readily secured by terrifying those in authority over them. 
Thus, a patient of my own, who for several years had suf- 
fered from attacks of hysterical mania, coming on at each 
menstrual period, and lasting for from six to ten days, made 
several attempts to kill herself with laudanum, but always 
took a dose so small that it produced no very marked result. 

In another case, a lady, from a Western city, stopping at a 
hotel, terrified her friends and excited the greatest commo- 
tion by threatening to jump out of a fourth-story window. 
When I saw her she was fastened down to the bed by straps, 
which had been taken from her trunks, and her husband, 
mother, and half a dozen chambermaids were supplicating 
her with tears in their eyes not to kill herself. To all of 
which she was replying that she was determined to jump 
from the window, and begging them to let her end her life at 
once. Without saying a word of entreaty or condemnation, 
I loosened the straps, opened the window, and told her to 
jump out. I added that she was rendering her husband un- 
happy, disturbing the guests of the hotel, and that the sooner 
she put an end to the trouble she was causing the better. The 
strap around her waist trailed along the floor as she got up, 
went to the window, and looked down on the street below. I 
placed my foot on the strap as a measure of precaution, 
though I was sure such an act was not necessary. The result 
was just as I had anticipated, for, after a moment's contempla- 
tion of the pavement, and applying no very polite epithet to 

1 Op. cit, p. 303. 



502 DESCRIPTION AND TREATMENT OF INSANITY. 

me, she went back to bed, and I heard no more of her suici- 
dal desires. 

But at times the termination is not so fortunate, and, not- 
withstanding the publicity with which threats are made, and 
the obvious object of them, the act of self-destruction is really 
accomplished. Thus, the Marquise de Prie, mistress of the 
Duke de Bourbon, was exiled from court, and, of course, 
indifference and neglect followed her in her retreat. She, 
however, resolved to regain, by a coup de theatre, the favor 
she had lost. She announced that on a certain day of the 
month, and at a certain hour, she would kill herself. Every 
one was amazed at the declaration that one so young, beau- 
tiful, and attached to life, contemplated suicide, and the news 
was received with derision. During the few days interven- 
ing, the Marquise gave several fetes, at which she danced, 
played, and amused herself as in the days of her highest 
favor. No one had ever seen her gayer, more spirited, more 
adorable. The hour arrived. She called the new lover she 
had chosen to her side, and again announced her determina- 
tion. The communication was received by him with a smile 
of incredulity. Believing it to be one of those mystifications 
to which she was accustomed, and that she was acting a part, 
he humored her so far as to give her, with his own hand, the 
draught she had prepared. It was in reality poison, and she 
died before assistance could be given. 1 

Although the vast majority of the cases of hysterical 
mania occur in women, it is by no means confined to the 
female sex, and many cases in men have been reported. 
Klein 2 has collected seventy-eight cases, and has added two 
others which have come under his own notice. The symp- 
toms do not vary essentially from those met with in women, 
though, perhaps, they do not reach the same degree of in- 
tensity. 

Two cases of well-marked hysterical mania, occurring in 
men who had for many years exhibited the ordinary phe- 
nomena of hysteria, have happened within my experience. 
In both of these there were paroxysms of delirium, character- 
ized by the existence of illusions, hallucinations, and delu- 
sions, and by persistent and systematic lying, and other at- 

1 Taguet, " Du suicide dans rhysterie," Annales medico-psychologiques, mai, 
1877, p. 347. 



3 tl 



De l'hysterie chez Thc-mme," Paris, 1880. 



EPIDEMIC INSANITY. 503 

tempts to deceive in matters of no importance. In the inter- 
vals between the paroxysms both patients were in a measure 
free from mental symptoms, though there were twitchings of 
the facial muscles, the globus hystericus, insomnia, and a 
hyperexcitable condition of the nervous system generally. 

The course of hysterical mania is rarely toward spontane- 
ous cure, unless the conditions under which it exists are 
changed for the better. Thus, marriage and the cessation 
of the menstrual function are favorable therapeutic factors. 
Under the influence of proper medical and hygienic treat- 
ment the affection can generally be kept in check, and often 
effectually cured, though relapses may occur. The fact, how- 
ever, must be recognized that, notwithstanding the generally 
beneficial influence of the menopause, there are cases in which 
this period is characterized by a recurrence of previously 
cured attacks, and others in which it is manifested for the 
first time. 

7l — EPIDEMIC INSANITY. 

Closely allied to hysterical mania is the form next to be 
described, which, on account of the manner in which it has 
prevailed, is called epidemic insanity. I say has prevailed, 
for it is exceedingly probable that, with advancing civiliza- 
tion and intelligence, future epidemics of insanity will be ex- 
ceedingly rare, if, indeed, the enlightened part of the world 
is ever visited by another. In a practical work, such as this 
is intended to be, this type of mental aberration need not 
long engage our attention. It is interesting mainly from a his- 
torical stand-point, and on account of the lessons it teaches 
relative to the forces by which the human mind is moved, 
and the depths of folly and ignorance which it can reach. 
The last epidemic of the kind occurred in France over twenty 
years ago, and has been well described by Dr. Cons tans. 1 

Several different types of epidemic insanity have existed. 
One of the most common was that in which the subjects were 
believed to be possessed by the devil — demonomania, as it is 
called. An epidemic of this form prevailed during the six- 
teenth and seventeenth centuries in many convents of Europe. 
It appears to have begun in a convent of the Ursulines at Aix, 
toward the end of 1609, by the confession of Madeline de 
Mandol, one of the nuns, that she was possessed by a great 
number of demons, and that she had been seduced by a sor- 

1 "Relation sur une epidemie d'hyst^ro-demonopathie in 1861," Paris, 1863. 



504 DESCRIPTION AND TREATMENT OF INSANITY. 

cerer, through their agency, before she had arrived at her tenth 
year. At this time Madeline was nineteen years old. Very 
soon afterward another nun, named Louise Capel, declared 
that she was possessed by three devils. 

At the time they made these confessions, these women 
were suffering from attacks of hystero-epilepsy, character- 
ized, as they are at the present day, by illusions, hallucina- 
tions, delusions, violent convulsions, and cataleptic seizures, 
all of which they ascribed to the demons who had taken pos- 
session of their bodies, which demons, they alleged, were 
under the command of a priest, Louis Gaufridi, a man of 
cultivation and strict morality. At first the accused man 
denied the charges made against him, and endeavored, by 
arguments addressed to the reason of his judges, to show the 
true nature of the seizures. The effort, however, was in vain ; 
public opinion was against him. Nothing was more firmly 
believed than the doctrine that the devil and his demons had 
power to enter the bodies of human beings and the lower 
animals. The Bible, which was then appealed to to settle 
all questions in morals, ethics, and science — pathology in- 
cluded — as well as theology, supported the view. Witches 
and sorcerers — women and men — who had made compacts 
with the prince of darkness, were religiously believed to be 
living in the very midst of the people, and the Bible had 
said, " Thou shalt not suffer a witch to live." 

From the excitement, from fear, and, perhaps, above all, 
by the force of the examples before him, Gaufridi became 
insane. He was affected with demonomania. He confessed 
all that was laid to his charge, and a great deal more that 
had not been imagined. He declared that he had worshipped 
the devil for fourteen years, and that he had engaged this 
demon to cause every woman on whom he breathed to become 
enamored of him ; that more than a thousand women had 
been poisoned by the irresistible power of his breath, and had 
been seduced by him ; and that Madame de la Pallude, the 
mother of Madeline, had been taken by bim, in an uncon- 
scious condition, to the sabbath, and violated by him. Of 
course, Gaufridi was burned at the stake ; but it is stated 
that the two nuns continued to be delirious. 

Among the convents visited was that of Sainte Brigitte at 
Lille. Several of the nuns had been present at the proceed- 
ings against Gaufridi, and had thus been subjected to infiu- 



EPIDEMIC INSANITY. 505 

ences readily capable of producing the disease. Among the 
sisters was one named Marie de Sains, who was remarkable 
for her many virtues, but who was now suspected of devot- 
ing herself to sorcery, and of being the cause of the posses- 
sions of the victims. She remained a year in prison with- 
out any formal proofs of her guilt being adduced, until at 
last she was positively accused by three of the sisters of hav- 
ing intercourse with the devil. At first the poor nun ap- 
peared to be surprised at this charge ; but, as was gener- 
ally the case, an accusation of intimacy with the devil was 
quite certain to induce demonomania in the accused person. 
It was not a surprising circumstance, therefore, that she 
should have recanted her denial and avowed herself the per- 
petrator of a series of such wicked and abominable acts that 
it was difficult to understand how the conception of them 
had ever entered her mind. Among them were numerous 
murders, stranglings of innocent children, ravaging of graves, 
feeding on human flesh, revelling in orgies of superhuman 
atrocity, unheard-of sacrileges, poisonings, and, in fact, every 
imaginable crime. In the presence of her accusers and exor- 
cists she improvised sermons which she ascribed to Satan, 
discoursed learnedly on the apocalypse, and made long dis- 
courses on anti-Christ. She declared, also, that at a sabbath 
Gaufridi had invented a diabolical charm, with which the 
devil was so greatly pleased that he had given him the title 
of u prince of magicians." This charm was composed of the 
sacramental body and blood, of the powdered flesh of the 
male goat, of human bones, skulls of infants, hair, nails, hu- 
man flesh, and the seminal fluid of the sorcerer, together with 
small portions of liver, spleen, and brain. 

There are many other things confessed by this demono- 
maniac, and set forth with horrible accuracy of detail by 
Lenormand, 1 and to a sufficient extent by Calmeil. 2 The epi- 
demic appears to have lasted in the Convent of Sainte Brigitte 
for about ten years. 

A more noted example of diabolical possession is that af- 
forded by the nuns of the Ursuline Convent at Loudun, in 
France, during the years 1632-35, and which resulted in the 
death at the stake of Urban Gfrandier, after he had been sub- 

1 " Histoire de ce qui s'est passe sous l'exorcisme de trois filles possedees es 
Flandres," etc., Paris, 1623. 

3 "De la folie," etc., Paris, 1845, t. i, p. 511. 



506 DESCRIPTION" AND TREATMENT OF INSANITY. 

mitted to the most atrocious tortures in order to make him 
confess to an alliance with the devil. These nuns presented 
all the symptoms of hystero-epilepsy in its worst form — that 
is, when modified by a bigoted and unhygienic religious life. 
During these paroxysms they accused their confessor, Urban 
Grandier, of having seduced them through the influence of 
the devil. Grandier, however, was made of stronger stuff 
than Gaufridi and Marie de Sains, and he died protesting his 
innocence to the last. 1 

Another noted outbreak was that which occurred in 1642 
at the Convent of Sainte Elisabeth, at Louviers. 

The following account of the symptoms exhibited by the 
possessed nuns is given by J. Lebreton, 2 a priest of that time, 
and who appears to have been an eye-witness of much that 
he relates. 

Fifteen nuns out of fifty in the convent were affected. 
They were noted for their piety, their gentleness, and excel- 
lent conduct in every respect. During the intervals of their 
paroxysms they conducted themselves with the utmost pro- 
priety. 

But when under the influence of the demons they exhib- 
ited a strange horror of the holy sacrament ; they made gri- 
maces and thrust out their tongues at it, spit on it, and blas- 
phemed against it with horrible impiety. They denied and 
cursed God, more than a hundred times a day, with frightful 
boldness and impudence. 

During these seizures they were affected with strange con- 
vulsions and contortions of their bodies, and among others 
was the bending of the body backward in the form of a bow, 
so that the body was supported on the forehead and feet 
without any other part of the body touching anything. They 
remained in this position a long time, and assumed it seven 
or eight times. After all these efforts and a thousand others, 
continued sometimes for four hours, they were as healthy, as 
fresh, as mild, the pulse as regular, as if nothing had hap- 
pened. 

1 For a full account of this episode of conventual life, see " Cheats and Illu- 
sions of Romish Priests and Exorcists discovered in the History of the Devils of 
Loudun. Being an Account of the Pretended Possession of the Ursuline Nuns, 
and the Condemnation and Punishment of Urhan Grandier, a Parson of that 
Same Town," Loudun, 1705. 

2 " La defense de la verite touchant la possession des religieuses de Louviers," 
Evreux, 1643. 



EPIDEMIC INSANITY. 507 

They accused their former confessor, Father Picard, and 
their actual one, Father Boulle, of having bewitched them 
through the agency of the devil ; and one of these, Madeline 
Bavan, made a detailed confession, not unlike those of Made- 
line de Mandol and. Louise Capel against Gaufridi. Picard 
had been dead several years, but Boulle was arrested and put 
to the torture. He steadfastly denied all the charges made 
against him. He was condemned to be burnt alive, the body 
of the dead Picard to be burnt with him, and, with the corpse, 
or what remained of it, fastened to his body, he suffered 
death August 21, 1647. 

The foregoing are a sufficient number of examples to show 
the horrible nature of those epidemics of demonomania as 
they occurred two or three hundred years ago in Europe. 
They were not confined to France. Italy, Spain, and Ger- 
many furnished fully as many and as notable instances. 

The epidemic of 1861, at Morzine, France, if less shock- 
ing in its manifestations, is only so because the thought of 
the age is more enlightened. It is probably the last of its 
kind, though even here it was kept alive by the exorcisms of 
silly ecclesiastics, and would certainly have been much more 
extensive but for the good sense and firmness displayed by 
Dr. Constans. This gentleman was sent by the French gov- 
ernment to put a stop to the epidemic, and he succeeded, not- 
withstanding the efforts made to thwart his plans. 1 

To dwell upon the epidemics of a similar character which 
have prevailed among Protestant sects, or those of tJieomania 
(among them are the Jansenists and others), though interest- 
ing, is not necessary to the elucidation of the subject. There is 
no essential point of difference between them. 2 A few words, 
however, in regard to a somewhat different type, lycantTiropy, 
will probably not be out of place. 

Lycanthropy is that form of mental derangement in which 
the individual believes that through the agency of the devil 
he is changed into a wolf at certain times. It is applied, also, 
to supposed transformations into other animals. It has pre- 
vailed epidemically, and isolated instances are even now occa- 

1 "Relation sur tine epidemie d'hystero-demonopathie in 1861." Par le Doc- 
tenr A. Constans, Paris, 1863. 

2 For a fuller consideration of these and analogous subjects, the reader is re- 
ferred to the author's work on " Certain Conditions of Nervous Derangement," 
New York, 1881. 



508 DESCRIPTION AND TREATMENT OF INSANITY. 

sionally met with, though not exactly presenting the same 
features as those of the sixteenth and seventeenth centuries. 

The first epidemic of the kind appears to have occurred 
in the latter part of the sixteenth century among the moun- 
tains of the Jura, in a place which, taking its name from an 
abbey founded there in the fifth century, was called Saint 
Oyant, and finally Saint Claud. 1 The inhabitants of the 
region about this abbey were entirely subject to the abbots, 
and were plunged into the lowest depths of ignorance, pov- 
erty, and superstition. 

Toward the end of the sixteenth century, lycanthropy ap- 
peared among these miserable people. Boguet, chief judge 
of the place, was charged with the duty of extirpating it, and 
he acquitted himself of his mission so faithfully that, accord- 
ing to Voltaire, he boasted, toward the end of his career, that 
he had strangled or burnt at the stake more than six hundred 
lycanthropes or demonolators. 

Boguet's mode of procedure was to order the arrest of an 
accused person on the testimony of a single witness, to put 
him into a dark and narrow cell, to subject him to the most 
cruel privations, and finally to apply torture, if it should be 
necessary, as many as three times. Under this system the vic- 
tim generally became insane, and confessed to all of which 
he was charged, and a great deal more. Boguet states in his 
work that the father testified against the son, the son against 
the father. Many took advantage of the fear and excitement 
that prevailed to accuse their enemies, and the depositions of 
little children were considered as being of especial importance. 

As in all periods characterized by the existence of some 
cause capable of rousing the most intense emotions of the 
mind, many persons, from thinking of the subject, and terror 
at the idea of being acted upon by the devil, or of being ac- 
cused of being in league with the powers of evil, became in- 
sane, and voluntarily came forward and made confession. 
They contracted the delusion that they were lycanthropes, 
that they ate children, destroyed sheep, and were in close re- 
lations with the devil and his demons. 

Thus, a woman, Pernette Gaudillon, as we learn from Bo- 

1 The account of this epidemic is derived mainly from Calmeil's " Histoire 
de la folie," who quotes from Boguet, the judge who tried the cases and who 
wrote a "Discours des sorciers," published in 1603-10; and from Voltaire, 
" (Euvres Completes," t. xxxix, edit, de Baudouin. 



EPIDEMIC INSANITY. 509 

guet, thought she was changed into a wolf, and, going on all 
fours through a field, seized a little girl, whose brother, aged 
fourteen, was engaged in gathering fruit. The boy defended 
his sister with courage, but Pernette, grasping a knife which 
he had in his hand, dealt him a blow in the throat, which 
speedily proved mortal. The people tore her to pieces. 

Pierre Gaudillon, her brother, was arrested on the charge 
of sorcery. He had the delusion that he had devoted his two 
children to the devil's service, and had taken them to a meet- 
ing of sorcerers. One day when his scythe acted badly, Sa- 
tan appeared to him and engaged him in his service. The 
demon was in the form of a black sheep, and spoke to him. 
He then went to the sabbath, where he met succubi and in- 
cubi. 1 He had often caused hail to fall. For magical pur- 
poses, he rubbed himself with an ointment .which the devil 
gave him. 

On dressing after having rubbed himself with this oint- 
ment, he felt himself transformed into a hare. Ordinarily, it 
was a wolf into which he was changed. When he was thus 
altered into a beast, his skin became covered with hair, and 
he took to running in the fields, attacking animals and even 
men when he was pressed by hunger. To change back into a 
man it was only necessary for him to rub himself with dew- 
covered grass. 

George Gaudillon, son of Pierre, and his sister Antoinette, 
were also accused of sorcery. 

George confessed that he went to the sabbath, and made 
use of an ointment to rub on his skin. He alleged that he 
had heard the devil speak, that he had seen succubi and incubi 
at the sabbath, and that he bore on his shoulder the mark of 
Satan. He declared that he had often been metamorphosed 
into a wolf, and had gone on four feet in the mountains. He 
had killed two she-goats during his nocturnal excursions. He 
rubbed himself in the dew-covered grass to become a man 
again. During the night of a holy Thursday he had re- 

1 A succubu3 was the name given to a female demon who, while the indi- 
vidual was asleep, had sexual intercourse with him. An incubus was a male 
demon, who had similar relations with women. The sexual orgasm, occurring 
during sleep in connection with lascivious dreams, was the origin of a belief 
which sent many a man and woman to the scaffold and the stake. At that 
period natural explanations were not sought. The tendency to look to what is 
called the supernatural is not yet extinguished in the minds of many otherwise 
enlightened persons. 



510 DESCRIPTION AND TREATMENT OF INSANITY. 

mained three hours in bed as if dead ; he came out of this 
stupor like a man awaking with a start from sleep. 

Antoinette Gaudillon affirmed that she had made the hail 
fall on the harvest, and that she had gone to the sabbath with 
her father and brother. She there had sexual relations with 
a black ram, the devil having taken this form for the pur- 
pose. 

All four of these maniacs were found guilty, were strangled, 
and then burned, their ashes being scattered to the winds. 

The following brief confessions, are taken by Calmeil from 
Boguet's work : 

Thievenne Paget. The devil appeared to me in full day- 
light, just as the loss of a cow had caused me great trouble. 
Hardly had I consented to give myself to him than he took 
me to a meadow where the sorcerers were accustomed to meet 
to celebrate the sabbath. There he had intercourse with me. 
Then he carried me through the air to the place whence he had 
taken me. The sexual organ of the devil is of the length and 
thickness of the finger ; the suffering during coitus with him 
is like that of an ordinary childbirth. Three times since my 
arrest I have had intercourse with the devil. Very often be- 
fore being put in prison I was transformed into a wolf. The 
devil went with me at night, when I ran in the mountains. I 
have killed many children ; I dragged them through the ra- 
vines and over the rocks till they died. I have assisted at the 
meetings of the sorcerers. I have killed cows and horses by 
pronouncing impious words, or simply touching them with a 
switch. 

Antoinette Tornier. I have been to the sabbath. I have 
there received the caresses of the devil ; he had the form of a 
black man. His penis does not exceed the finger in size. I 
have danced with a demon disguised as a ram. His foot, 
which he offered me for a hand, was rough to the touch. I 
have made charms to change rain into hail, and have drank 
with sorcerers out of a wooden vessel. 

Antide Colas said that the devil had come to her one even- 
ing under the guise of a tall man dressed in black, and muf- 
fled in a long beard. In an instant she felt herself going 
through the air, and was soon in the midst of the sabbath. 
Subsequently the devil came and took her, from time to time, 
from her bed, and transported her to great distances by 
taking her by the head and causing the sensation of a cold 



EPIDEMIC INSAOTTY. 511 

wind. This woman had a fistulous opening near the umbili- 
cus, and surgeons had often probed it. She declared that it 
was into this opening that the devil was accustomed to intro- 
duce his genital organ, while marital connection was effected 
by the ordinary way. 

This woman had impulsions to suicide, which were 
thought to be instigations of the devil. 

Clauda Jean Prost declared that she had assisted as often 
as she could at the feasts of the demons. She had assisted 
at the dances of the sorcerers, and had transformed rain into 
hail. Often she had been changed into a wolf. 

Clauda Jean Guillame possessed, she said, the art of 
changing herself into a wolf. She boasted that she had in 
an hour strangled two children in the mountains, and had 
also strangled a dog that had protected them. 

Jacques Bocquet had been to the sabbath. He had resisted 
the importunities of the devil that he would give him his 
daughter, for whom he had conceived a violent passion. He 
accused himself, however, of having poisoned many persons. 
He had changed himself into a wolf and gone to the moun- 
tains after having rubbed himself with a certain ointment. 

The three last named stated that they had more than once 
united in the work of killing children, and they gave the 
names of ^.ve of these that they had also partially eaten. 
They and the others avowed that they transformed them- 
selves into wolves, and in this guise had killed many children, 
whose names they gave. Finally they confessed that, in 1597, 
they had met two children of Claude Baut ; that they had 
killed the girl, but the boy had saved himself by flight. 
They generally ate parts of the children they killed, but 
never touched the right side. The fact of these murders was 
verified as well by the evidence of the fathers and mothers 
as by that of the villagers generally, who testified that the 
children named had been killed by wolves at such and such 
•times. It is needless to say that all these lunatics were burned 
at the stake. 

Calmeil says of these poor wretches : 

"The singularity of the hallucinations of Thievenne Paget 
and Toinette Tornier, who described the shape and size of the 
sexual organs of the devil, is surpassed by the strangeness of 
the sensations of Antide Colas, who imagined that the sexual 
congress between her and the devil was by means of the fistu- 



512 DESCRIPTION AND TREATMENT OF INSANITY. 

Ions opening which she had in the linea alba. The astonish- 
ment of the judges when these women described their sensa- 
tions is thus expressed by Boguet : 

"' Ugliness and depravity are shown by Satan in his 
carnal knowledge of these sorceresses. To some he appeared 
in the form of a black man ; to others, as some beast or other 
— dog, cat, he-goat, or ram. He knew Thievenne Paget and 
Antoinette Tornier as a black man, and when he had relations 
with Jacques Paget and Antoinette Gaudillon, he took the 
form of a black ram with horns. Frangoise Secretain has 
confessed that her demon sometimes appeared as a dog, some- 
times as a cat, sometimes as a cock, when he wished to know 
her carnally. 

" ' It is necessary,' he continues, ' that I report a strange 
but well-established circumstance. Antide Colas de Breton- 
court, being a prisoner at Baume, for the crime of sorcery, 
and having been visited, was found to have a hole in the 
belly just below the navel, in addition to the natural open- 
ing. This was probed on the 11th of July, 1598, by Master 
Nicholas Milliere, surgeon, and its existence shown beyond 
doubt. And then the sorceress confessed that her devil, 
whom she named Lizabet, knew her carnally by this opening, 
and her husband by the natural one. But what will be 
thought of the fact that Satan knew these sorceresses in 
prison ? Nevertheless, they have confessed to it, as has also 
Thievenne Paget, who says that while she was a prisoner the 
devil approached her three times.' " 

These are by no means all. Boguet is a faithful chroni- 
cler of the ravings of these lunatics, and of his own assiduity 
in ridding the world of witches, whom he religiously believed 
had sold themselves to the devil, and were enemies of the 
human race. He has, however, furnished the student of 
psychology with one of the most striking histories to be 
found in the whole range of the science. 

Other places caught the infection, and lycanthropy be- 
came well known, engaging the utmost powers of the civil 
and ecclesiastical law to subdue the devil in the new field 
of operations he had selected. And it was not confined to 
France ; it had its foci in Spain, Germany, Italy, and even 
in Scotland, but, as wolves were rare in this latter country, 
the maniacs believed that they took the forms of crows, hares, 
foxes, cats, dogs, and other animals. Doubtless, in some 



EPIDEMIC INSANITY. 513 

cases, the subjects had abnormal sensations in various parts 
of their bodies, especially of the skin, which originated the 
delusion of their transformation. Dr. Max Simon x cites from 
De Yier a case in which such an origin apparently existed. 
There was in Padua, in 1541, a man who thought himself a 
wolf, and who ran about the country, attacking and putting 
to death all whom he met. After much trouble he was cap- 
tured. He then said, in confidence to those who had arrested 
him, "I am truly a wolf, and if my skin does not look like 
that of a wolf, it is because it is turned, and that, therefore, 
the hair is inside." To assure themselves of the fact, they 
cut him in different parts of his body, and finally amputated 
his legs and arms ; then, not finding the hair, they began to 
think they were mistaken, and sent the poor wretch to a sur- 
geon, who, however, notwithstanding all his skill, could not 
save his life. 

It would be interesting to consider the various epidemics 
of tarentlsm, or dancing mania, and the other forms of 
convulsive seizures, attended with mental aberration, which 
have prevailed at different times, both in Europe and in this 
country. All of these were hysterical in character and existed 
in times of great emotional excitement, which excitement 
was almost invariably of a religious character. As I have 
said, however, no additional light could be thrown upon the 
subject under consideration, and those interested in it can 
readily study it from other sources. 3 

The rationale of the spreading of epidemics of insanity 
is not difficult to understand. Most of the cases occurred in 
women, and hence the hysterical element was a notable fea- 
ture in the affection. In hysteria of all kinds the propensity 
to imitation is great. A single hysterical woman in a par- 
oxysm will infect a whole ward of other women, as all hos- 
pital physicians know. This was one factor in causing the 
extension of the several manias that became epidemic. A 
second was the well-known fact, seen in our own day, that 

1 "Le monde des reves," Paris, 1882, p. 172. 

3 Hecker's "Epidemics of the Middle Ages," Sydenham Society Translation. 

Brigham's " Observations on the Influence of Religion upon the Health," 
etc., Boston, 1835. 

Figuier's "Histoire da merveillenx," etc., Paris, 1860. 

Mathieu's ' ; Histoire des miracnles et des convulsionnaires de Saint-M6dard," 
Paris, 1864. 

Hammond's " Certain Conditions of Xervous Derangement," Xew York, 1881. 
83 



514: DESCRIPTION AND TREATMENT OF INSANITY. 

when some remarkable event takes place — a great crime, for 
instance — there are always many persons whose minds, con- 
stantly trembling in the balance between reason and insan- 
ity, only need some snch excitement to tnrn the scale against 
them. Hence they are apt, when the perpetrator is being 
sought for, to come forward and confess themselves gnilty of 
the crime, and to court the punishment awarded to the offence. 

A third was the ignorance and superstition which then 
prevailed in the world, and which induced the belief in the 
existence of devils and demons, whose business it was to en- 
trap the souls of men and women by giving them worldly 
power in return for their eternal damnation hereafter. These 
influences were amply sufficient, as they would be now if 
they existed in like force, to cause the propagation, from one 
person to another, of any particular form of insanity. 

And even now we see occasional instances of what exam- 
ple and the power of sympathy, much less powerful factors 
than those I have mentioned, but doubtless contributing 
somewhat to aid the work, will do in causing the spread of 
insanity. Upon two occasions within the last year instances 
of the kind have occurred in New York. In one of these a 
woman became insane in the street. Her two daughters were 
with her at the time, and they both became affected with a 
like form of mental aberration within an hour or two after- 
ward, and all three were sent to an asylum the next day. 
The other case occurred during the present month — January, 
1883. A woman suddenly became affected with what, from 
the account given in the public press, was probably hysteri- 
cal mania. One after the other her five daughters, all of 
adult, or nearly adult, age, were similarly attacked, and it 
became necessary to send the whole family to an asylum. 
We have seen how, in the epidemic of lycanthropy, some of 
the particulars of which I have given, the victims were, many 
of them, members of the same family. 

The folie d deux, or folie communiquee of the French, are 
names applied to insanity which is transmitted by one person 
to another with whom he is thrown in contact. In an inter- 
esting paper Dr. Brunet ' gives several instances of this propa- 
gation, among them the following : 

The woman, M., as a consequence of a great disappoint- 

1 " Contagion de la folie," Annates medico-psychologiques, November, 1875, 
p. 337. 



EPIDEMIC INSANITY. 515 

ment, showed evidences of mental aberration. She was in a 
constant state of exaltation, thinking that she was pnrsned by 
powerful enemies with all kinds of terrible weapons. Living 
with her was her daughter, aged thirteen, a very quiet young 
person, who had never shown any disposition to mental dis- 
orders. At first she endeavored to soothe and reassure her 
mother, but ere long she herself became similarly affected. 
They uttered horrible cries of terror, and, in order to escape 
from their invisible enemies, rushed from the house, and went 
to sleep in the fields. MM. Lasegue and Falret, 1 after citing 
and commenting on seven cases of communicated insanity, 
arrive at the following among other conclusions : 

One of the individuals is the active element, is more intel- 
ligent than the other. He creates the delusions, and imposes 
them little by little upon the second person, who is the pas- 
sive element. Resisting at first, he ends by accepting the 
ideas submitted to him, but alters them more or less. He 
thus reacts on the first person, and thus the two eventually 
come to exhibit the same delusions in the same way. 

In order that this end may be accomplished, it is neces- 
sary that the two persons should live together a long time, 
with the same interests, habits, feelings, fears, and hopes. 

And, third, the delusion must possess the semblance of 
probability. 

These conclusions will not account for the cases cited, nor 
for many others that have been reported. It is not, there- 
fore, a matter of surprise to find that they are regarded by 
some alienists as being insufficient to explain facts in regard 
to the truth of which no doubt exists. Thus, M. Marandon 
de Montexel 2 arrives at conclusions more in consonance with 
the present state of the question. There are three varieties 
of transferred insanity. 

1. La folie imposee (imposed insanity), in which a lunatic 
imposes his delirant conceptions on another intellectually 
and morally weaker than himself. 

2. La folie simultanee (simultaneous insanity), in which 
two (or more) persons hereditarily predisposed contract at the 
same time the same delirium. 

1 "La folie a deux ou folie cominuniquee," Annates medico-psychologiques, 
November, 187T, p. 321. 

2 " Contribution a l'etude de la folie k &eux"Annales medico-psychologiques, 
Janvier, 1881, p. 28. 



516 DESCRIPTION AND TREATMENT OF INSANITY. 

3. Lafolie communiquee, in which a lunatic communicates 
his hallucinations and his false conceptions to another person 
hereditarily predisposed to insanity. 

An interesting case of communicated insanity * is that of 
the Dubourques, father and son, the latter of whom is in con- 
finement in a lunatic asylum for attacking women and kill- 
ing one, and whose case has already been alluded to under 
another head. Here the father had imbibed the delusion that 
his brother had died in California, leaving him a large for- 
tune, which had been appropriated by the government to its 
own use. Talking to his son, a weak-minded young man, he 
had gradually indoctrinated him with the truth of his false 
conceptions, and the two for several years were seen every 
day on Broadway carrying signs on their backs, stating that 
they had been defrauded out of a large fortune by the United 
States Government, and demanding the restitution of the 
money. There was no truth whatever in these statements, 
except that a brother of the old man had died in Califor- 
nia. Neither he nor the son ever took the least pains to 
ascertain whether any money was left or not. At last the 
father died, and for a year or more the son walked alone. 
Finally, he committed the acts for which he is now in confine- 
ment. 

Kiernan, 2 in an interesting communication on the subject, 
has adduced the case of a clergyman who, being insane, in- 
doctrinated five other lunatics with his delusions. He also 
mentions the interesting fact that general paralytics very fre- 
quently enter into each other's delusions. To this point I 
shall return when the subject of general paralysis comes to be 
considered. 

1 The term folie d deux does not apply to all cases of the affection, as in 
some more than two persons are affected. It appears to me that, at any rate for 
English writers, the name " Communicated Insanity " is preferable. 

2 " Contributions to Psychiatry," Journal of Nervous and Mental Disease, 
October, 18S0, p. 639. 



VOLITIONAL MORBID IMPULSES. 517 

CHAPTER VI. 

IT. 

VOLITIONAL INSANITIES. 

The forms of mental aberration comprised under the des- 
ignation of volitional insanities are those in which the will 
is deranged, either in the way of exaltation or of excessive 
action, or in that of depression or of diminished action. By 
some authors it is contended that there can be no derange- 
ment of the will, for the reason that this faculty, if it ever is 
a faculty, is simply the result of ideation, and were there no 
ideas there would be no will. It is only sufficient, without 
going into the metaphysics of the question, to call to mind 
the fact that many of those persons who are strong of will 
are weak in ideas, both as regards their quantity and 
strength. An obstinate person, for instance, is by no means 
necessarily markedly intellectual. 

Besides, experience teaches us that there are cases of men- 
tal aberration characterized by the features mentioned, and 
by very little disturbance of the other categories of mental 
faculties. It is these which I propose to bring to the notice 
of the reader, leaving to metaphysicians the task, if they de- 
sire it, to determine the exact nature of the will. That we 
have such a faculty every person who moves his finger knows. 

a — VOLITIONAL MOKBID IMPULSES. 

By a volitional morbid impulse we understand those men- 
tal factors which cause the perpetration of acts which are 
neither dictated by an idea or an emotion. They are, there- 
fore, motiveless, and are often perpetrated against the ideas 
and the desires of the subject. 

Neither are they to be confounded with those acts per- 
formed by epileptics in a state of unconsciousness, and which 
resemble, in their external and more obvious characteristics, 
morbid volitional impulses. Very Little observation is re- 
quired to distinguish the one from the other. 

The paroxysm may arise suddenly without any premoni- 
tory symptoms ; and, when the act to which the individual is 
blindly impelled is committed, the normal balance between 
the several mental faculties is at once restored. A similar act, 



518 DESCRIPTION AND TREATMENT OF INSANITY. 

or any other from like excitation, may never again be per- 
formed. Usually, however, there is more or less tendency to 
a repetition of some kind. 

Or there may be cerebral symptoms for a longer or shorter 
period before the culminating phenomenon occurs. These 
consist of pain, vertigo, heat, a sensation of fulness, of tight- 
ness, or of weight, and generally of insomnia. 

It is related of Garrick, the celebrated comedian of the 
last century, that one day, while riding along the road in 
company with some friends, he suddenly descended from his 
horse, and, rushing toward a rider who was approaching, 
dragged him to the ground, and began applying his whip to 
him with a degree of vigor more astonishing than agreeable 
to the recipient. After he had administered a sound thrash- 
ing, the actor took off his hat, and was profuse in his apolo- 
gies, both to the victim and his friends, who had looked on 
in amazement. "I could not help it," he said. "I never 
saw the gentleman before, and I beg ten thousand pardons 
for my outrageous conduct. I am willing to make any repa- 
ration in my power. Here is my whip ; he may revenge him- 
self on my hide ; but I could no more have helped acting as 
I did than I could have flown." This is a good example of 
a volitional morbid impulse in which there was neither an 
idea to be executed nor an emotion to be gratified. 

Marc * cites the following case : 

K., aged eleven years and a half, was of backward mind, 
nervous, lazy, malicious, and obstinate. One day, when he 
refused to work, his mother permitted him to stay at home 
with her, and made him assist her in cleaning the house — 
moving the furniture, bringing hot water, etc. Finally, she 
told him to remain in the kitchen, and to keep the fire going 
in the stove. While thus occupied, he saw under the table 
a little hollow gourd used as a cup. Into this he put a live 
coal, and placed the whole in the thatch of the roof. "It 
came to me suddenly," he said, "and I was obliged to do 
it." A month subsequently he experienced an "infernal 
heaviness" in his head, and again he felt obliged to kindle 
a fire. On both occasions, as soon as the act was committed 
the impulse was satisfied, and he was the first to endeavor to 
extinguish the flames. 

1 "Dela folie considered dans ses rapports avec les questions medico-judi- 
ciaires," Paris, 1840, t. ii, p. 390. 



VOLITIONAL MORBID IMPULSES. 519 

Georget " gives a full account of the case of Pierre Joseph 
Delepine, a backward boy of sixteen. This youth had, with- 
out motive, attempted eight times to set fire to his father's 
house. He even, while in prison, put live coals in his bed, 
and then lay down on it while it was on fire. 

Jacoby 3 quotes the case of Barbara Erkhow, a Eussian 
peasant, who was delivered of a son, and was, two weeks 
afterward, left at home with her husband's mother. While 
Barbara was nursing her infant^ the mother-in-law made a 
fire in the stove, and soon afterward left the room. In an 
instant Barbara seized her child and threw it into the stove. 
She then lay down on a bed which was in the chamber. Al- 
most immediately afterward her mother-in-law re-entered the 
room, saw the infant in the fire, and snatched it from the 
flames. The child died in her arms. Barbara could not ex- 
plain her conduct otherwise than by declaring that she had 
been seized with a sudden impulse to throw her infant into 
the stove, and that she had done so without thought or cause. 

In 1828, a man, named Papavoine, killed in the forest of 
Yincennes two little boys, who were there on a holiday with 
their mother. He had never seen these children before, and, 
when seized with the impulse to kill them, went and bought 
a knife for the purpose, and, returning, murdered them be- 
fore their mother's eyes, and made his escape. On being 
arrested and identified, he at first denied the charge, but 
subsequently admitted its truth. Confined in prison, he set 
fire to his bed, and attempted to murder a fellow-prisoner. 
When interrogated during his trial, he declared that at the 
time of the double murder he was in bad health, had been 
unable to sleep, and was nervous. He asserted that he had 
had no motive whatever to kill the two children. Inquiry 
into his antecedents showed that, though he had been quiet 
and taciturn in his habits, he had never exhibited any indica- 
tions of insanity, but had discharged with fidelity the duties 
of an office he had held under the government, and had re- 
tired with a pension. The plea of insanity was put forward 
by his counsel, but it was disregarded by the jury, and he 
was found guilty and executed. 

A few weeks since, a lady of this city brought her daugh- 
ter to me, to be treated, as she said, for u nervousness." The 

1 "Discussion m6dico-legale sur la folie," Paris, 1826, p. 130. 

2 " Considerations sur les monomanies impulsives," These de Berne, 1868, p. 12. 



520 DESCRIPTION" AND TREATMENT OF INSANITY. 

patient was eighteen years of age, in good general health, and 
suffered from no disorder of her menstrual function. While 
I was talking with her she suddenly rose, and, walking rap- 
idly across the room, overturned a chair which stood against 
the wall. She then returned, and went on with her conver- 
sation. Her face was a little more flushed than it had been, 
but I noticed no other change. 

After a few minutes I said to her : " Why did you throw 
over that chair ? " 

"I don't know," she answered. 

" Do you know that you did throw it down % " 

"Oh, yes ; of course I know all about it." 

" Then why did you do it % " 

" I was obliged to. I cannot tell you any more." 

"Did you want to do it % " 

"No ; I had no wish about it." 

"Had you been thinking about the matter % " 

" No ; I had no thought about it ; I felt compelled to do 
it." 

"Have you ever done the like before % " 

" Many times. I have torn books, broken plates and other 
things, and once I rushed out in the rain without any shoes." 

"And you can't tell me why you do these things % " 

"No, except that I am obliged to do them. As soon as I 
feel an impulse of the kind I do it, and then I am satisfied." 

" Have you never tried to resist \ " 

"No, for there is nothing to resist. I don't think I could 
stop. I have no wish to do them, and no thought of doing 
them. I just do them, and that is all there is about it." 

"But you might do serious injury some day." 

" Yes, I have thought of that, and it gives me a great deal 
of trouble. But what can I do % " 

In another case the patient, a gentleman who had received 
a serious wound of the head during the late civil war, con- 
sulted me for the cerebral symptoms that were developed, as 
well as for the irresistible impulses to which he was subject. 
I found on examination that the missile — a fragment of shell 
— had struck him in an oblique direction immediately over 
the external angle of the left eye, doing at the time apparently 
no greater damage than to plough a furrow in his skull, and to 
knock him senseless for a few minutes. The wound healed 
without trouble, and in a couple of weeks he was fit for duty. 



VOLITIONAL MOKBID IMPULSES. 521 

He served as an officer of artillery all through the war, and 
then resumed the practice of the law. But, shortly after he 
had taken up his residence in a large western city, he began 
to suffer with his head. He had pain at the seat of the in- 
jury, repeated attacks of vertigo, and almost daily redness of 
the corresponding side of the face, attended with a roaring 
sound in the ear and a complete stoppage of the left nostril, 
so that it was impossible to force the air through it. These 
paroxysms lasted about two hours, and then gradually went 
off, there being at the same time a profuse discharge of nasal 
mucus. 

But, in addition to these troubles, there was another, which 
gave him still greater anxiety. He was subject to occasional 
impulses, which came on without warning, which were unas- 
sociated with any idea, which were entirely purposeless, which 
were not prompted by any emotion, but of which he was thor- 
oughly conscious, though unable to resist. Indeed, the ques- 
tion of resistance never arose in his mind any more than it 
did when he automatically took out his watch to see what 
time it was while he was busy writing or thinking of some 
business matter. As yet he had committed no very flagrant 
violation of the rules of propriety, the worst being that on the 
day previous to his visit to me he had thrown a heavy ink- 
stand through the window of his office. The deed was done 
in an instant, and without the least reflection or knowledge 
that he was about to do it. Other acts had consisted of break- 
ing wine-glasses while at dinner, throwing water on the floor, 
and tearing leaves out of books. On one occasion he had 
broken a costly thermometer which stood on a table in a 
friend's library. 

These acts were apparently instinctive and automatic. 
The epileptoid element was entirely absent. He was per- 
fectly conscious both at the time they were perpetrated and 
afterward, and had full knowledge of all the steps of the per- 
formance. That they and others similar, to which attention 
has been directed, were due to lesions of the will, is, I think, 
perfectly clear. 

And I think that authors generally have shown a disposi- 
tion to confound all morbid impulses as being due to like 
factors. Undoubtedly, some which have been considered as 
volitional are ideational or emotional ; but, making due allow- 
ance for these, there are others in which the will alone of all 



522 DESCRIPTION AND TREATMENT OF INSANITY. 

the mental faculties is deranged. Esquirol 1 saw this very 
clearly when he wrote : " There exists a species of homicidal 
monomania in which neither intellectual nor moral disorder 
is to be observed. The murderer is urged by an irresistible 
power, by a force which he cannot conquer, by a blind im- 
pulse, by an irreflective determination, without interest, with- 
out motive, without mental confusion, to an act which is both 
atrocious and contrary to the laws of nature." If the intelli- 
gence can be abolished or perverted, if the moral sensibility 
can be similarly affected, why cannot the will, the comple- 
ment of the intellectual and moral being, also suffer in like 
manner ? Why should not the will be influenced by troubles, 
by perturbation, by morbid weakness % What incomprehen- 
sibility is there in such an idea % 

M. de Castelneau 3 speaks to a like effect when he says : 

" Instantaneous, transitory, temporary mania is a mental 
disorder which is manifested suddenly at the instant of the 
seizure. The subject is forced by the action of his suddenly 
disordered will to the perpetration of automatic acts which 
have not been foreshadowed." 

Kiernan 3 regards mania transitoria as simply a variety of 
acute mania. This is undoubtedly true as regards some cases, 
such, for instance, as those which have been designated as 
"fury"; but it is not, I think, correct of all cases, especially 
of those which are now under notice. Indeed, mania transi- 
toria has, like morbid impulses, been made to embrace many 
different affections. 

Billod, 4 in an elaborate memoir, discusses the question of 
lesions of the will very thoroughly, and adduces many exam- 
ples of its derangement. Among them is the case of R., who, 
with a relatively fair integrity of the intellectual faculties, 
had almost constant irresistible impulses to travel and to 
steal. After a time the former ceased, but the latter not only 
continued, but were still more strongly developed with time. 
Nothing seemed to arrest his tendency to steal whatever he 
could lay his hands on. As soon as he saw anything, he en- 

1 " Des maladies mentales," Paris, 1838, t. ii, p. 341. 

2 "De la folie instantanee considered an point de vue medico-judiciaire," 
Ann. med.-psychologiques, 1857, p. 307. 

3 " Contributions to Psychiatry," Journal of Nervous and Mental Disease, 
October, 1880, p. 631. 

4 "Des maladies de la volonte," Ann. med.-psy., 1847; also, "Des maladies 
mentales et nerveuses," Paris, 1882, t. i, p. 144. 



VOLITIONAL MORBID IMPULSES. 523 

deavored to steal it. He would crawl up behind a person and 
try to seize with his teeth the hat held in the hands ; at other 
times he would drag himself along the floor on his hands and 
knees in order to snatch something he felt impelled to steal. 
For more than a year he was in the asylum, and, notwith- 
standing the fact that he was kept most of the time restrained 
by a camisole, which prevented the free exercise of his hands, 
he managed to commit many thefts. It was not necessary 
for the objects stolen to possess any value ; a stone, a Wade of 
straw, a piece of paper, were fully as much the objects of his 
impulse as valuable articles. One day, as Dr. Billod passed, 
with some papers pertaining to a patient just arrived, R. 
rushed at him, forcibly seized the bundle between his wrists, 
and vainly endeavored to drag it away. R. was always calm, 
affectionate, reasonable, even, when there was nothing in 
sight that could excite his kleptomaniacal propensity. He 
greatly regretted and deplored his bad tendencies, and he 
had entire consciousness of his mental state. "I am wrong," 
said he; "I know it is madness, but what can I do? It is 
stronger than I. At the time the impulse to steal comes over 
me I am wild. I cannot compare my condition then to any- 
thing but drunkenness." 

This patient presents features in some respects similar to 
those of the young lady affected with emotional kleptomania, 
but differing in the important element of there being a total 
absence of motive, a feature which characterizes all true vo- 
litional morbid impulses. 

Esquirol ' relates the case of a man, thirty-two years old, 
of a nervous temperament and quiet disposition, who had 
been well educated, and who was fond of the fine arts. He 
had suffered from a brain disorder, but had been several 
months cured. After being in Paris for about two months, 
during which time he led a perfectly regular life, he one day 
entered the Palais de Justice and attacked an advocate with 
great fury. The next morning, when seen by Esquirol, he 
was perfectly tranquil and composed, showed no anger what- 
ever, and had slept well all night. The same day he designed 
a landscape. He recollected what he had done the previous 
day, and spoke of it with calmness. He declared that he had 
entertained no ill-will against the advocate, had never even 
seen him before, and had no business with him or any other 

1 " Des maladies mentales," Paris, 1838, t. i, p. 380. 



5 2 ± DESCRIPTION AND TREATMENT OF INSANITY. 

lawyer. He could not understand, he said, what had actuated 
him to make the assault. Subsequently, he exhibited no in- 
dications whatever of being insane. 

It often happens that with the performance of a single act, 
due to volitional morbid impulse, the tendency is exhausted 
and never reappears. 

Volitional morbid impulses may be exhibited in many 
ways, constituting instances of homicidal mania, suicidal 
mania, kleptomania, pyromania, etc. Sometimes two or more 
of these forms exist in the same individual. 

b — ABOULOMANIA (PARALYSIS OF THE WILL). 

Under the designation of aboulomania (<z/3ou\o?, irresolute, 
and pavia, madness) I propose to describe a form of insanity 
characterized by an inertness, torpor, or paralysis of the will. 
So far as I am aware, Billod ! was the first to call attention to 
this condition, in which, while there is an inability to exert the 
will, the other mental faculties are not necessarily affected. 

The disorder, like other mental diseases, may arise sud- 
denly, or it may, as is generally the case, be developed gradu- 
ally after a more or less decidedly marked set of prodromatic 
symptoms. These latter may continue throughout the course 
of the affection, and consist of pain in the head, occasional 
sensations of vertigo, insomnia, noises in the ears, and other 
symptoms indicative of the existence of a hypersemic condi- 
tion of the brain, though they were present but in one of the 
cases — the fourth to be described — that have come under my 
notice. In the other cases there appeared to be rather pas- 
sive congestion without other head symptoms than insomnia 
and occasional headache. 

M. Billod details the particulars of the case of a patient, 
a notary, in whom the phenomena of the disorder in question 
were strongly shown. If he desired to go out, he could not 
exert his will to the extent of causing the proper actions to 
be performed, and so with many other movements. The de- 
rangement was, however, most strikingly shown when he at- 
tempted to execute a legal paper. He signed it, but when he 
came to affix his paraph 2 — his paraph, it is true, was of a very 
complicated character, but he had always been able to execute 

1 " Des maladies de volonte," op. cit., loc. cit. 

2 A flourish with the pen immediately under the signature, and which, in 
France, Spain, and Italy, is necessary to the validity of legal papers. 



ABOULOMANIA (PARALYSIS OF THE WILL). 525 

it with ease — it was in vain that he fought against the difficulty. 
A hundred times, at least, he tried to execute the movements 
necessary to the perfecting of his signature, but his hand re- 
fused to move. So long as he only made the motions in the 
air just above the paper there was no trouble, but as soon as 
the pen touched the paper he could not move. He strove with 
all his might to accomplish his object, till the sweat stood 
out in beads on his forehead. Then he rose with impatience 
and stamped upon the floor ; reseating himself, he tried again, 
but with no better success. The contest lasted three quarters 
of an hour, and then he succeeded in making the paraph, but 
a very imperfect one. 

M. Billod was witness of another struggle, which was of 
much longer duration. The patient wished to go out shortly 
after dinner. He wished, he said, to get an idea of the ap- 
pearance of the city. For five days he made many attempts 
to start. He would get up, take his hat, and get ready for 
his walk, but further than this he could not go ; his limbs 
could not be made to make the requisite movements. He 
could not will them to do so. " Would any one," he said to 
M. Billod, "believe in the existence of such an affection ? I 
am evidently my own prisoner. You do not hinder me from 
going out, since, on the contrary, you wish me to go. My legs 
are in good condition, they are not paralyzed, since, as you 
see, I walk w^ell. What is it, then \ " He then complained of 
not being able to will, notwithstanding his wishes. Finally, 
at the end of five days, he succeeded in getting out, but re- 
turned in five minutes, covered with perspiration, and as 
much exhausted as though he had run several miles. 

Instances of this impossibility of exerting his will occurred 
at every moment. If he wished to go to the theatre, he could 
not go ; if at dinner with congenial friends he wished to take 
part in the conversation, he could not say a word. There was 
always the powerlessness to do what he desired. It is true 
that often this want of power did not exist, but even then 
there was the fear of it, and generally his fears were realized. 

A lady of this city, who had enjoyed good health up to 
the period of the cessation of the menstrual function, suffered, 
subsequently, in a way very similar to that of M. Billod's 
patient. She came under my observation in the spring of 
1880, and I found the following-described condition to exist : 

There were no cerebral symptoms of a somatic character 



526 DESCRIPTION AND TREATMENT OF INSANITY. 

except an inability to sleep, with which she had suffered for 
several months, though not to any very great extent, as she 
usually obtained about five hours sleep every night. The 
circumstance, however, which gave her most concern was an 
inability to exert her will in accordance with her desires. If 
the thing to be done was of no consequence, and more of the 
nature of a routine act requiring no deliberation, there was 
rarely any trouble ; but if it was a matter to be discussed, or 
which presented an alternative, or which required a deter- 
mination to be made, then the difficulty of bringing the mind 
to bear upon it was of such a nature as to render the perform- 
ance an impossibility. She thus transacted all her household 
duties which had become habitual to her without experienc- 
ing any inconvenience ; but, if something out of the ordinary 
every-day run of events had to be done, there was sure to be 
an impossibility of her doing it. If, for instance, it was sug- 
gested that she should go to Saratoga, she at once assented 
and expressed pleasure at the idea ; but when the time came 
she could not make the necessary preparations. If these were 
made for her, and the hour approached for her to go to the 
station, she became still more helpless : she could do nothing 
connected with the journey. The putting on of her bonnet 
was a task beyond her powers, and she had to be literally 
dragged to the door and placed in the carriage that was to 
convey her to the train. Arrived at the station, she could 
not get out of the carriage, and again aid was necessary. All 
this time she would utter lamentations over her inability to 
act for herself, while expressing her desire to make the journey. 

The question of accepting or not accepting invitations 
always gave her a great deal of trouble. She would deter- 
mine, perhaps, after much hesitation and many changes, that 
she would accept, and then the matter of writing the note 
came up to increase the difficulty. The getting the paper, 
the taking hold of the pen, the dipping of it in the ink, and 
writing the note, were all acts that she could not accomplish. 
She was not even able to ask some one else to write it for her. 
The consequence was that she rarely went into society, al- 
though naturally of a cheerful disposition and fond of gayety. 

Her life was, therefore, not only a burden to herself, but 
to those around her ; and lately her trouble had increased so 
much that, as she said, she saw no refuge but a lunatic asylum. 

During her interview with me she exhibited no evidence 



ABOULOMAISIA (PARALYSIS OF THE WILL). 527 

of her disorder till I asked her to put out her tongue. Proba- 
bly she had not been requested to do so for many years, and 
it was, therefore, an act to which she was not accustomed. 
Evidently she tried very hard to show me her tongue, but 
she could not even open her mouth. The muscles of her face 
were contorted ; her eyes rolled, her mouth twitched, but it 
was not opened. At last she said, quite calmly, "I can open 
my mouth perfectly well, as you see now, but I cannot do 
it when you ask me. As soon as I feel the desire, the im- 
possibility of exerting the will begins. I can do it very well 
if I do not think about it." It appeared to me at first that 
she labored under some defect of speech analogous to stam- 
mering. I had often seen people act in a similar manner when 
told to utter a word beginning with a labial consonant ; but 
her subsequent performances dismissed this idea. Desiring 
to examine her spine, I requested her to adjust her dress for 
the purpose. "I should like to oblige you," she said, "but 
I cannot begin. I cannot raise my hands for that object. I 
can move them about, but it is impossible for me to take off 
my cloak." I suggested that she should try hard to send a 
volitional impulse to her hands, so as to make them unbut- 
ton her cloak. She got red in the face, and the perspiration 
started out on her forehead, but her hands remained still on 
her lap. "No, I cannot do it," she said, "not if the salvation 
of the world depended on it." Eventually her daughter was 
obliged to remove her cloak for her, and otherwise arrange 
her clothing for the object I had in view. She dressed her- 
self without the slightest difficulty. 

When it came to leaving my consulting-room, she rose 
from her chair in haste and went toward the door, as if deter- 
mined to overcome all resistance ; but as she approached it 
she began to hesitate, and finally stopped, unable to go a step 
farther. She then came back, and sat down as if in despair. 
But soon she made another effort, with no better result. She 
could not pass through the door, and it was necessary for her 
daughter and myself to take her, each by an arm, and lead 
her out to her carriage. 

In another case, that of a gentleman from Massachusetts, 
there was an inability to exert the will solely in the matters 
of dressing and undressing himself. He would go to his bed- 
room, but as soon as he began to consider the subject of un- 
dressing, his indecision was shown. He would, after stand- 



528 DESCRIPTION AND TREATMENT OF INSANITY. 

ing some time thinking of the subject, sit down and begin to 
unlace one of his v shoes. Then the question would arise 
whether he had not better take off the other one first. After 
cogitating over this point for several minutes, he would be- 
gin with the other shoe, but then again doubts would arise, 
and he would stop. Perhaps, then, he would rise and walk 
up and down the floor, deliberating over the question, when, 
looking toward the glass, he would see himself reflected, and 
his eyes would catch sight of his necktie. u Ah," he would 
say to himself, " of course that is the thing to take off first." 
But as soon as he took hold of it he hesitated, and the mo- 
ment he hesitated he was powerless. And so it went on if 
he was left to himself, till it has frequently happened that 
daylight would find him still with every stitch of clothing on 
him. In the morning it was the same thing in putting on his 
clothes. He could never determine which stocking should go 
on first, or whether his shirt should be put on before his 
stockings, or even whether the right or left leg of his drawers 
or trousers should have the preference. 

It is this phase of the disorder to which I think the term 
" aboulomania " is especially applicable. 

This gentleman suffered severely from insomnia and occa- 
sional headache, but there was no mental aberration other 
than that of his will. 

In another case, similar in all essential respects to the fore- 
going, so far as putting on and taking off the clothing were 
concerned, there was the additional phenomenon of an impos- 
sibility of determining which bed to sleep in. The patient, a 
gentleman of this city, had two beds in his room, and he 
could never will which one to occupy. Often, as he told me, 
he had passed the whole night vainly endeavoring to decide, 
and ending by thorough exhaustion and falling asleep in a 
chair, or on the floor. At one time he thought to avoid the 
difficulty by having one of the beds removed, but this caused 
him so much mental uneasiness that he was obliged to have 
it brought back. Finally he hit upon the device of having 
his mother decide for him by putting, every night, a placard 
on one of the beds with the words written on it, ' ' This is the 
bed you are to sleep in to-night," and then he had no trouble. 
If by any chance the placard was forgotten, the old irreso- 
luteness returned, and neither bed was occupied. 

Cases similar to these have been reported by other authors. 



ABOULOMANIA (PARALYSIS OF THE WILL). 529 

Dr. Carpenter 1 quotes from Dr. J. H. Bennett's " Mesmeric 
Mania of 1851 " the following instances : 

" The first was that of a gentleman who frequently could 
not carry out what he wished to perform. Often, on en- 
deavoring to undress, he was two hours before he could get 
off his coat, all his mental faculties, volition excepted, being 
perfect. On one occasion, having ordered a glass of water, 
it was presented to him on a tray, but he could not take 
it, though anxious to do so ; and he kept the servant 
standing before him half an hour, when the obstruction was 
overcome. 

"In the other case the peculiarity was limited. If, when 
walking in the street, this individual came to a gap in the 
line of houses, his will suddenly became inoperative, and he 
could not proceed. An unbuilt- on space in the street was 
sure to stop him. Crossing a street, also, was very difficult ; 
and on going in or out of a door he was always arrested for 
some minutes. Both these gentlemen graphically described 
their feelings to be ' as if another person had taken possession 
of their will.'" 

Under the designation of "Folie du doute (avec delire 
du toucher) " Dr. Legrand du Saulle has described a condi- 
tion which, at first thought, appears to have some relations 
with that under consideration. Further examination, how- 
ever, shows that the affection he has studied so thoroughly is 
in reality quite different. But M. Cabade, 2 under a similar 
title, has given the particulars of a case which is in many re- 
spects identical with those herein cited. 

The patient, a man, thirty-four years old, was of a neu- 
rotic family, and had suffered from an attack of acute rheu- 
matism with certain cerebral complications. The progress of 
the disease toward recovery was slow and painful, but eventu- 
ally he seemed to have quite recovered. Hardly, however, 
was convalescence established when he began to experience 
symptoms of the affection I have called "mysophobia," and 
which has been fully described in a previous chapter of this 
treatise. Then came troubles of volition. He could not make 
up his mind to pass through a door ; before succeeding, he 
made many fruitless attempts, and often members of his 

1 "Principles of Mental Physiology," etc., London, 1874, p. 385. 

2 "Un cas de folie du doute," IS encepTiale, journal des maladies mentales et 
nerveuses, October, 1882, p. 454. 

84 



530 DESCRIPTION AND TREATMENT OF INSANITY. 

family were obliged to encourage him by words, and even to 
aid Mm with their own hands to accomplish the act. 

From this time on he could not perform the most simple 
acts of life without difficulty and hesitation, and, when he 
had at last succeeded, he repeated them many times. For 
instance, if he were seated and wished to change his place, 
he would rise, then sit down, then rise again, and so on, ten, 
fifteen, twenty times, before he could decide to take a step 
toward the point he desired to reach. If he were walking, 
and encountered a tree or a rock, he stopped before it, then 
retraced his steps, then resumed his original direction, stopped 
again, went back, returned, and so on, ten or twenty times, 
before he was able to pass the imaginary obstacle. Often, in 
order to pass the tree or stone which he came to in his walks, 
he was obliged to run. Often, after having succeeded, he 
would retrace his steps, and then the whole series of hesita- 
tions was gone over again. Thus, one day, entering the con- 
sulting-room of M. Ball, he went out again quickly, then 
returned, saying, "I was afraid I had come in badly." 

In addition to this trouble with his will, the patient was 
also affected with intellectual subjective morbid impulses, a 
disorder to which I have already called attention. Thus, 
while suffering from hesitation, either in passing an object 
or in doing some other thing, he pronounced in a loud voice 
words which showed that he was possessed of an idea with- 
out relation to the act he was endeavoring to perform. At 
the beginning of his disease he repeated certain words which 
had struck him as being singular, or which had a special sig- 
nification — for example, the word "corbillard." Later, he 
often repeated expressions of affirmation or denial, as if he 
were protesting against some imputation. "No, no; I am 
not this, I am not that. No, I am not guilty of such or such a 
thing." These words were accompanied with gestures of one or 
both hands, as if he were endeavoring to repulse some person 
or thing. From this it is evident that the case had its com- 
plications. Subsequently he had other attacks of rheuma- 
tism, and contracted syphilis. He also became the victim of 
morbid fears of various kinds ; but, notwithstanding all these 
things, he married, and the account of the case ends with the 
mention of the difficulties he experienced in abstaining from 
cohabitation with his wife and continuing anti-syphilitic treat- 
ment. 



ABOULOMANIA (PARALYSIS OF THE WILL). 531 

Paralysis of the will or aboulomania may be produced 
by certain diseases and drugs. In hysteria, for instance, it is 
often the case that the patient takes to her bed, and remains 
there for months, or even years, without any other reason 
for so doing than that her power of volition is destroyed or 
greatly impaired, and that, therefore, she cannot get up and 
go about her work or duties. It is well known, too, that alco- 
hol and opium have the effect of weakening the will to such 
an extent as to render the subject absolutely incapable of 
taking the initiative in any important undertaking, or of re- 
sisting influences brought to bear upon him, and which he 
knows he ought to resist. Wills are thus made, and property 
given away, which the individual knows he ought not to exe- 
cute or part with, but with his diminished volitional power 
he yields, because he is not strong enough to successfully 
oppose^ 

De Quincey 1 sets out the volitional degradation of the 
opium-eater very forcibly when he says of him that he " loses 
none of his moral sensibilities or aspirations ; he wishes and 
longs as earnestly as ever to realize what he believes possible 
and feels to be exacted by duty, but his intellectual appre- 
hension of what is possible infinitely outruns his power, not 
of execution only, but of power to attempt. He lies under 
the weight of incubus and nightmare ; he lies in sight of all 
he would fain perform, just as a man forcibly confined to his 
bed by the mortal languor of a relaxing disease, who is com- 
pelled to witness injury or outrage offered to some object of 
his tenderest love. He curses the spells which chain him 
down from motion ; he would lay down his life if he might 
but get up and walk ; but he is powerless as an infant, and 
cannot even attempt to rise." 

It would appear, however, that in some cases of aboulo- 
mania there exists what has been called by Mr. Skey 9 the 
"latent force" of the will, which can be brought out, as in 
hysterical subjects, by some strong impression made upon the 
mind, or some exceedingly important object to be accom- 
plished. This " latent force " exists to some extent with all 
persons, even in the healthy state. To use a simile suggested 
by Mr. Skey, let us suppose that a strong man has found by 
experience that he can barely lift two hundred and fifty 

1 " Confessions of an English Opium-Eater." 

2 " Six Lectures on Hysteria," etc., London, 1866. 



532 DESCRIPTION AND TREATMENT OF INSANITY. 

pounds of sand with the utmost exertion of his will and 
muscles. Put two hundred and sixty pounds of gold before 
him, and tell him that, if he lifts it, it is his, and he will raise 
it without difficulty. 

The ancients were fully aware of the existence of this " la- 
tent force." It is told of Alexander the Great that one day, 
while sitting in front of his tent, a soldier passed him stag- 
gering under the weight of a bag of gold he was carrying to 
the treasury. "My friend,'* said the King to him, "do not 
suffer so painfully. Carry the bag to your own tent, for it 
is all your own," and the soldier tripped off with the load as 
easily as though the sack had been changed for one of feathers. 

The woman, also, who has been in bed for years, unable, 
as she thinks, to stand alone, and in whom the will power for 
certain acts is almost entirely abolished, jumps from her bed 
and runs nimbly down stairs if the house catches fire. Her 
latent will power, which only a strong impression can bring 
out, is at once developed, and she does what no ordinary 
excitation could possibly accomplish. 

And the same is true of aboulomania occurring in persons 
unaffected with other diseases — a primary affection in fact ; 
and the fact is well exemplified in the first case of the kind 
to which my attention has been directed, and to which I have 
alluded in another place. 1 In this instance a gentleman never 
could make up his mind how to invest his money, and every 
day he would go down town to Wall Street, thinking that at 
last he had found the investment to make, but always re- 
turning in the morning without having accomplished his pur- 
pose. Day after day this conduct was repeated, and several 
months elapsed without his money being invested. 

I then lost sight of this patient, and did not see him again 
till the latter part of the year 1882, when he again came under 
my charge. In answer to my inquiries, he informed me that 
the trouble about the money had been settled, soon after I 
last saw him, by his wife taking it from his desk and pur- 
chasing some securities with it, but that soon afterward an 
extension of his hesitation had ensued, and that now there 
were many things he could not do. He had given up trying 
to invest his money, but he now had a like difficulty in buy- 
ing anything, no matter how trifling, and this was a source 
of great disturbance to him. If, for instance, he went into 
1 "Cerebral Hyperemia," etc., New York, 1879, p. 29. 



ABOULOMANIA (PARALYSIS OF THE WILL). 533 

a shop to get a pair of gloves, he could never determine for 
himself what kind to buy, or what colors ; and, when helped 
out in these matters by the salesman, he could not go through 
the movements necessary to getting out his pocket-book to 
pay for them. As a consequence, he either had to have some 
one with him to pay for the things he bought, or, as fre- 
quently happened, he would throw the articles down on the 
counter, and tell the people to send them home. At first, 
before he began to take some one with him to aid him in 
making purchases, he would often spend an hour or more in 
getting some commonplace article. But, upon one occasion, 
as he was walking along Broadway, the idea occurred to him 
that he would take a box of bonbons home to his daughter. 
He entered a shop which he thought was one he was in the 
habit of frequenting, purchased an expensive box, and had 
it filled with the finest sweetmeats in the shop. All this was 
only accomplished after a large expenditure of time, and after 
the display of much hesitation, which not only annoyed him, 
but caused many expressions of disgust from the shopkeeper. 
Finally, when he came to pay for the purchases, he found, as 
usual, all his difficulties increased, and this was a part of the 
procedure in which he would not be assisted by the dealer. 
After fumbling at his pocket for some time in the vain en- 
deavor to get at his money, he requested that the things 
might be sent home. He had already found out that the 
shop was not the one he had intended to enter, and that he 
was unknown to the proprietor. He was not, therefore, sur- 
prised when that person informed him that the box could not 
leave his place till it was paid for ; but he was not prepared 
for the torrent of abuse which was rained upon him. The 
effect, however, was very different from what either of the 
contracting parties anticipated. In an instant my patient 
became entire master of the situation. He took out his porte- 
monnaie with as much decision as he had ever done anything 
in his life, laid the exact sum on the counter, and then, taking 
the box, threw it at the shopkeeper, and walked as composedly 
to the door as though nothing had happened. But the influ- 
ence which had brought out his " latent force" was not yet 
lost. He stopped at the right shop, a few doors off, selected 
his bonbons without the slightest irresoluteness, and paid for 
them with as much ease as in the last purchase. The next 
day, however, he was as bad as ever. 



53J: DESCRIPTION AND TREATMENT OF INSANITY. 

It would appear from cases such as these that the general 
condition of- cerebral excitement produced by certain factors 
carries with it an augmentation of the power of the will ; 
and it is not at all improbable that the pathological condition 
causing aboulomania is a state of passive congestion or anae- 
mia. Carpenter, 1 referring to this state, says that " the strong- 
est volitional effort may be inoperative through some defect 
of the apparatus by which the nerve-force is transmitted to 
the muscles which are to execute the behests of the will, as 
happens in paralysis. But there are states — and it is these 
which are now under consideration — of absolute incapacity 
for such effort, the mental desire existing, while the energy 
necessary to carry it into effect is deficient. That this inca- 
pacity arises from a deficient supply of blood to the ideational 
(cerebral) nerve-centre appears probable from the familiar fact 
that a general deficiency of volitional power over the muscles 
is a marked feature of the physical depression which betokens 
feebleness of the circulation, being especially noticeable in sea- 
sickness, while a defect in the distributive action of the vaso- 
motor system of nerves (such as that of which we have evi- 
dence in many local congestions) might very well account for 
such cases as the two following." a . . . 



CHAPTER VII. 
v. 

COMPOUND INSANITIES. 

Compound insanities are those forms of mental aberration 
in which two or more categories of the faculties of the mind 
are involved to a marked degree. In all the types to be con- 
sidered under this heading there is, therefore, a general men- 
tal derangement, the perceptions, the intellect, the emotions, 
and the will participating in the disturbance ; and often with 
alternating predominance, or no special predominance, of one 
set over the other. 

1 Op. cit., p. 385. 2 These are the cases cited on page 529. 



ACUTE MANIA. 535 



a — ACUTE MANIA. 



By acute mania is to be understood a condition of mental 
derangement characterized by illusions, hallucinations, delu- 
sions, great mental and physical excitement, and often by a 
tendency to the perpetration of acts of violence and extrava- 
gance. 

Pinel ' defines acute mania as an affection in which there 
is a general and permanent hyperexcitability of the intel- 
lectual and moral faculties. It is exhibited by the most de- 
cided symptoms — alteration of the countenance, disorder of 
the clothing, acts of violence, and confusion of ideas, which 
succeed each other without order and without logical se- 
quence. It is, moreover, characterized by intense nervous ex- 
citement, by extreme agitation, sometimes reaching the point 
of fury, by a general and more or less well-marked delirium, 
and often by a complete reversal of all the operations of the 
mind. 

Broussais 8 says : 

" Maniacs are agitated, vociferous; they are irritated by 
the slightest cause, and even without provocation, but espe- 
cially if they are spoken to. It is only sufficient to speak to 
them to excite them to the highest degree. Their ideas are 
incoherent, their eyes bright, their muscular strength pro- 
digious. It is often necessary to restrain them, for they are 
actuated by the wish to break and destroy everything which 
comes within their reach, and they kill those who approach 
them unless they are kept in subjection. Some of them, when 
the accession has been sudden, had already murdered several 
persons before they could be confined. Many turn with fury 
against themselves, and stab or throw themselves from heights. 
The pulse is small and tense, and more or less quick. Some- 
times there is scarcely any acceleration in the action of the 
heart. When they have not been bled, the face is red and 
swollen, the veins enlarged, the skin hot, the tongue red, the 
epigastrium tender to the touch, anorexia, and sometimes a 
yellowish tinge about the eyes. They can remain a long time 
in this deplorable state without food, without sleep, without 
feeling cold, yelling and blaspheming day and night, making 

1 " Traite medico-philosophique sur F alienation mentale," Paris, 1809, seconde 
Edition, p. 139. 

a " De l'irritation et de la folie," deuxieme Edition, Paris, 1839, t. ii, p. 352. 



536 DESCRIPTION AND TREATMENT OF INSANITY. 

every effort to break the bonds which secure them, and al- 
ways dangerous if they succeed in so doing." 

This is a graphic picture of the acute maniac of fifty years 
ago. Fortunately, few such are now encountered. Acute 
mania is generally, but not always, preceded by a prodro- 
matic stage, in which the symptoms are similar to those 
which precede the development of other forms of insanity. 
The period of incubation may last several days, or even weeks. 

The most prominent symptoms which others observe in a 
person about to become the subject of acute mania are exces- 
sive irritability of temper from very slight causes, a general 
condition of unreasonableness, suspicions against those he has 
always esteemed and trusted, and marked changes in his 
modes of feeling and of expression. His subjective symp- 
toms are pain or uneasiness in the head, vague fears, for 
which he cannot account, an indisposition to indulge in men- 
tal efforts, and often an impossibility of concentrating the at- 
tention on any matter requiring any considerable amount of 
thought, wakefulness, and sleep, when obtained, inquiet and 
disturbed by morbid dreams. 

As the affection advances to fuller development, these 
symptoms are all increased in violence, and others make their 
appearance, going to establish a more or less radical change 
in the character of the individual. His dislike of friends and 
relations becomes pronounced, and he either treats them with 
unnatural indifference, or exhibits a degree of active hostility 
productive of ill feeling and quarrels. He does things in 
other ways, which excite the astonishment of those who have 
long known him. From having been economical, he becomes 
prodigal ; from having been temperate and sedate in language, 
he becomes extravagant and profane ; from having held the 
most moral sentiments, he expresses licentious and obscene 
views ; his ideas are expressed in incoherent language, and 
often the ideas themselves are illogical and incomprehensible. 
His handwriting becomes more or less illegible, words are 
omitted, letters are dropped, he misplaces the date and signa- 
ture, and introduces phrases which have no relation to the 
subject of which he is writing. His digestion becomes im- 
paired, his tongue is coated, his breath is foul, his bowels are 
constipated, his appetite is at times extinguished, and again 
increased to the point of gluttony, his skin is hot and dry. 

With all this he is entirely regardless of what others may 



ACUTE MANIA. 537 

think and say of him. He bears no interference with his 
plans, which are often impossible of execution, and he be- 
comes careless of his person and his dress. 

This state may, as I have said, last several days or weeks, 
till, either gradually or through the action of some cause more 
than ordinarily exciting, it passes at once into the fully devel- 
oped stage. Again, there may be no well-marked prodro- 
matic stage, and the explosion occurs with startling sudden- 
ness. 

And in some cases there may be a sudden accession of 
acute symptoms lasting only a few minutes, and followed by 
a period of comparative repose, during which the disease is 
permanently developed, or in which there is the establish- 
ment of a subacute form with frequent exacerbations of de- 
lirium. 

The following case is an instance of this mode of accession 
and of the course of the type in question : 

A gentleman, a widower, lived upon terms of great affec- 
tion with his sister, who managed his establishment for him. 
For several years, they had occupied the same house together 
without anything occurring to disturb the sincere attachment 
which existed between them. He was as careful as possible 
to provide for all her wants, and exhibited a tenderness and 
love for her which were noticeable to all with whom they were 
thrown in contact. 

One morning at breakfast, without any premonitory indica- 
tions of a change in his conduct having been observed, he re- 
moved his boots, took off his coat, and seated himself at the 
table in this condition. His sister, surprised at these acts in 
one who had always been remarkably punctilious in all his 
social observances, inquired his reasons for such strange be- 
havior, and made some laughing remark on the subject. He 
returned no answer, but, jumping up from his chair, began 
to swear and curse in the most violent manner. Becoming 
alarmed for her personal safety, she made her escape from the 
room and sent for the family physician. Gradually, how- 
ever, her fears abated, and, approaching the door and hearing 
no noise within, she entered the room. To her great astonish- 
ment, she found her brother properly clothed, seated at the 
table as if nothing had happened, and waiting for her to pour 
out his coffee for him. At first he appeared to be in entire 
ignorance of his singular conduct, but at last he admitted 



538 DESCRIPTION AND TREATMENT OF INSANITY. 

that he believed he had taken off his coat and boots, and 
sworn a little. He excused himself by saying that his feet 
hurt him, and that he had felt very warm. 

Nothing further evidencing any mental derangement took 
place till she began to notice a change in his demeanor toward 
her. He found fault with her personal appearance, said she 
arranged her hair badly, that her dresses were unbecoming, 
and that she was awkward in her movements. Then he ac- 
cused her of neglecting the household, declared that she was 
ruining him with her extravagance, that her conduct toward 
him was disrespectful and insulting, and that if she did not 
amend her ways he should be forced to send her out of his 
house. She bore all his unkindness with great patience, and 
tried to convince him of the erroneous character of his im- 
pressions. But she might as well have attempted to change 
the course of the sun. His delusions had become fixed as a 
part of his mental being, and all efforts made to dissipate 
them only served to plant them deeper in his mind. Finally 
it became very obvious that he had acquired a decided aver- 
sion to her, and at last so hateful had the sight of her be- 
come that he ordered her to leave the house, giving her but 
three days in which to make her preparations for departure. 
Before she left his residence he had another attack of de- 
lirium which lasted several hours, and during which he at- 
tempted to cut his throat. Not till the occurrence of this 
second paroxysm did she have any idea that his conduct to- 
ward her was the result of insanity. After it passed off she 
spoke of his condition to other relatives, but no action was 
taken in regard to putting him in an asylum. The day sub- 
sequently to this attack he came home with a common woman 
whom he installed as housekeeper, and his sister took her 
departure. 

After that I saw him frequently, and could discover no 
evidence of mental aberration, except that he had delusions 
relative to his sister, and that she and others had conspired 
to prevent him disposing of his property, as he thought fit. 
He had, in fact, made a will, which, however, was never exe- 
cuted, giving all his property to his housekeeper. He ap- 
peared to transact his extensive mercantile business with as 
much thoroughness as ever. 

But about ten days after his second attack of delirium he 
had a third, which was very severe, and which lasted about 



ACUTE MANIA. 539 

twelve hours. Up to this time lie had never accused his 
sister of anything worse than disrespect, extravagant con- 
duct, and neglect to provide for his comfort. After this last 
attack he informed me one morning, in a very confidential 
manner, that she had made two unsuccessful attempts to 
poison him. 

Such cases as this are, however, rare. Ordinarily, there is 
a continuity of the delirium. Remissions there may be, but 
intermissions, except in the form known as periodical in- 
sanity, are very uncommon. In this latter variety of mental 
alienation the symptoms entirely disappear, and the patient 
is, to all intents and purposes, sane. 

In the beginning of an attack of acute mania the mental 
symptom which is most prominent is the exaggeration of all 
the faculties of the mind. The perceptions are deranged, and 
there are both illusions and hallucinations, especially of the 
senses of sight and hearing. They may be of a pleasing, a 
frightful, or an indifferent character, and these several forms 
may alternate with surprising rapidity. At one moment the 
patient sees images which, to judge from the expression of 
his face, are causing him intense satisfaction, when instantly 
a change ensues in the nature of the forms or circumstances 
depicted, and he raves with terror or rage. 

As regards hearing, he will stop in his walk, assume an 
attitude of listening intently, while a rapt smile passes over 
his face, and his hands are raised to command silence, when 
suddenly he utters expressions of fright or anger, places his 
hands over his ears, or puts his head between his knees, or 
under the bedclothes, in the vain attempt to shut out the 
sounds which madden him. 

It is quite common for the acute maniac to mistake those 
persons who are about him for others ; and even inanimate 
objects are, through his illusion, changed into men and women, 
or animals of various kinds. Again they appear to him as 
angels or devils, who either approach him with benevolent 
or evil intentions, as the case may be. 

The sense of hearing is often exalted to a surprising de- 
gree, and very slight sounds are thus often heard at a distance 
which seems almost impossible. I have known a whispered 
conversation, conducted in a room on the first floor of a house, 
to be heard by a patient suffering from acute mania in bed in 
a room on the second floor, all the doors between being closed. 



540 DESCRIPTION AND TREATMENT OF INSANITY. 

All the other senses may be the subjects of illusions and 
hallucinations, though not generally to the same extent as 
those of sight and hearing. The taste may be perverted to 
such an extent that substances taken as food have the flavor 
of noxious drugs, and odors generally regarded as pleasant 
may smell like some rotten substance. A patient of mine, to 
whose nostrils a nurse held a handkerchief sprinkled with 
cologne- water, exclaimed, " Take it away ; you are trying to 
poison me with small-pox. I know the smell ; take it away, I 
say ! " and she closed her nostrils with her fingers and put 
her head under the bedclothes in her fright. Though illu- 
sions or hallucinations of the sense of touch are probably 
not common in acute mania, there is very generally a remarka- 
ble exaltation to tactile impressions, while the ability to feel 
pain is greatly lessened. Patients exhibit this first-named 
characteristic by taking off their clothing as fast as it is put 
on them, and keeping themselves as naked as possible. The 
contact of a single garment, or of the bedclothes, is irritating, 
and hence it is not surprising that they prefer to denude 
themselves of all clothing. 

But while this condition exists there is, at the same time, 
an indifference to painful impressions which is astonishing. 
A man will hack himself with knives, inflict extensive muti- 
lations on himself, and even plunge his head into the fire, 
and exhibit expressions of satisfaction while so doing. I 
have repeatedly asked patients after recovery whether or not, 
while they were in the act of perpetrating the most terrible 
wounds upon sensitive parts of their bodies, they had felt 
pain ; and the invariable answer has been in the negative. 
Either no pain was experienced, or the sensation was pleas- 
urable. A lady, during an accession of acute mania, and 
while left alone in her room for a few minutes, cut off both 
nipples with pieces of glass which she obtained by break- 
ing a lamp-shade. At the same time her fingers were, in 
several places, cut to the bone. Several months afterward, 
when she had recovered her sanity, she told me that she 
had mutilated herself in consequence of having a delusion 
that she would poison her baby (a year old) if she allowed 
him to take her breast, and that the best way to stop nurs- 
ing him was to make the act impossible. So far from feel- 
ing any pain, the operation was pleasant, and, if she had not 
been prevented, she would have cut off both breasts as 



ACUTE MANIA. 541 

well. The sensation, she said, was an agreeable feeling of 
titillation. 

In another case, the patient, a man suffering also with 
acute mania, had waked np in the night, and, while his 
attendant slept, had extirpated both testicles with a pair of 
dull scissors. After the operation, during which he had lost 
a good deal of blood, he woke the nurse, and, handing him 
the testicles, told him to give them to the ducks. I saw this 
patient several years afterward. He had then been sane for 
over two years, but had symptoms of an approaching recur- 
rence. I inquired in regard to his former attack, and, among 
other points, asked why he had emasculated himself, and 
whether or not he had experienced any pain while so doing. 
He replied that he had felt a burning sensation in the testi- 
cles, that they seemed to him to be balls of fire, and that cut- 
ting them out had not only relieved him of his suffering, 
but had been attended with pleasurable feelings. 

During the time when it was the custom to put to the 
torture and burn at the stake the maniacs who believed them- 
selves witches or sorcerers, and who were supposed to be in 
league with the " powers of darkness," it was a subject of 
observation that the poor wretches, while being subjected to 
the action of agencies capable of causing the most acute pain, 
appeared to experience very little if any suffering. This im- 
munity was ascribed to the fact that the devil looked after his 
own. In reality, however, it was due to the analgesic con- 
dition so frequently present in maniacs. 

The illusions and hallucinations which afflict the subject 
of acute mania invariably involve the intellect, and are ac- 
cepted as actual occurrences ; as a consequence, there are de- 
lusions in accordance with the character of the sensorial aber- 
rations, and these are the mainsprings of the involvement of 
the emotions and the will, and of the conduct of the patient. 
His delusions have with him all the force of beliefs based 
upon the most undisputed facts. 

At the same time, delusions may arise independently of 
illusions or hallucinations, . being formed spontaneously or 
from the renewing by the mind of old beliefs and their re- 
elaboration into abnormal conceptions. 

A delusion having the same power with a maniac as a 
rational belief with a sane person, it is not surprising that 
acts of violence, extending even to murder and suicide, are 



5±2 DESCRIPTION AND TREATMENT OF INSANITY. 

committed. A maniac, for instance, imagines that the nnrse 
coming toward him with a dose of medicine is an enemy ap- 
proaching with an axe in a menacing attitude. The illusion 
is complete, and is accepted with unquestioning faith in its 
correctness. He consequently seizes a stool, or some other 
convenient weapon, and dashes out the nurse's brains. Or he 
constructs, without any sensorial basis other perhaps than his 
depraved sense of taste, the delusion that the medicine given 
him by the physician is poison ; he attributes whatever sense 
of physical discomfort he may have to its action ; he refuses 
to take it, and it is administered by the agency of a stomach- 
tube. Feeling himself the victim of a conspiracy to poison 
him, and experiencing the fear and the anger such a belief is 
calculated to inspire, he secretes a knife about his person, 
and, waylaying the physician, kills him not only without 
regret, but with the satisfaction a sane man would experience 
at killing a person who, he believed, was endeavoring to mur- 
der him. Or the delusion may be based upon such terrible 
hallucinations or illusions that, to escape from what he deems 
to be dangers that he cannot resist, seeing, as he imagines, 
the utter hopelessness of saving himself from frightful tor- 
ments, he throws himself, in his terror and despair, from a 
window, or kills himself with some weapon that chances to 
be at hand. 

Again, instead of being affected with delusions of a hor- 
rible or terrifying nature, the subject of acute mania is im- 
bued with beliefs of the most enjoyable character. Every 
one he meets is a friend or a superior being, and his jolliness 
and good humor never desert him. Or, as is not uncommonly 
the case, the two varieties, with all intermediate grades, may 
alternate in the same individual. 

Besides the matter of false beliefs or delusions, there are 
very often in the beginning of attacks of acute mania a sharp- 
ness and clearness of the intellect which are decidedly abnor- 
mal in character. He becomes cunning and adroit, is con- 
stantly on the qui vive against deception, and may even 
develop talents which no one ever suspected him of possessing. 
One, for instance, who has never shown the least mechanical 
skill or knowledge of ship-building, will construct a miniature 
vessel, perfect in all its parts ; another, who has never ex- 
hibited the slightest ability as an artist, will paint a very fair 
picture, or make a sketch with pencils, that in his sane state 



ACUTE MAMA. 543 

lie would not think of attempting ; and a third, who has had 
no experience as a speaker, will deliver orations with a man- 
ner and a diction that evince a good deal of oratorical talent, 
if they are somewhat inflated and exaggerated in their lan- 
guage. 

Relative to this division of the subject, Dr. Rush ' says : 
"The records of the wit and cunning of madmen are numer- 
ous in every country. Talents for eloquence, poetry, music, 
painting, and uncommon ingenuity in several of the mechan- 
ical arts, are often evolved in this state of madness. A gentle- 
man, whom I attended in our hospital in the year 1810, often 
delighted as well as astonished the patients and officers of our 
hospital by his displays of oratory in preaching from a table 
in the hospital yard every Sunday. A female patient of mine, 
who became insane, after parturition, in the year 1817, sang 
hymns and songs of her own composition, during the latter 
stage of her illness, with a tone of voice so soft and pleasant 
that I hung upon it with delight every time I visited her. She 
had never discovered a talent for poetry nor music in any pre- 
vious part of her life. Two instances of a talent for drawing 
evolved by madness have occurred within my knowledge ; 
and where is the hospital for mad people in which elegant 
and completely rigged ships and various pieces of machin- 
ery have not been exhibited by persons who never discovered 
the least turn for a mechanical art previously to their derange- 
ment % Sometimes we observe in mad people an unexpected 
resuscitation of knowledge ; hence we hear them describe 
past events, and speak in ancient or modern languages, or 
repeat long and interesting passages from books, none of 
which, we are sure, they were capable of recollecting in the 
natural and healthy state of their mind." 

It is reported that a lady, becoming delirious, spoke in a 
language which no one about her understood. At last a per- 
son heard her who recognized the fact that she was talking 
in the Breton tongue, and it was then recollected that she 
was born in Brittany, but had left that part of France when 
she was a young child, and had entirely forgotten the lan- 
guage. 

Coleridge 2 cites the case of a young woman who could 

1 "Medical Inquiries and Observations upon the Diseases of the Mind," 
fourth edition, Philadelphia, 1830, p. 151. 

2 "Biographia Literaria," London, 1847, vol. i, p. 117. 



544 DESCRIPTION AND TREATMENT OF INSANITY. 






neither read nor write, but who in her delirium talked Latin, 
Greek, and Hebrew. It was supposed by a priest that she 
was possessed of a devil, and preparations were made to ex- 
orcise him ; but at last some one remembered that the girl 
had been a servant to an old Protestant pastor, whose habit 
it was to read aloud from his favorite authors within the 
hearing of the girl. The words and sentences spoken by the 
girl had, many of them, been written out, and, on being com- 
pared with the books, so many identifications were obtained 
that there was no reasonable doubt as to their source. 

Of course, the emotional system is greatly disturbed in 
cases of acute mania. Indeed, some of the most striking evi- 
dences of the disorder of the mind which exists are exhibited 
through the emotions. With every false perception and every 
delusion there is a display of passional activity in accordance 
with its character, and which is as variable as the exciting 
cause. It is no uncommon event to see maniacs exhibiting 
love and hatred, benevolence and revenge, and many other 
antagonistic feelings, in the course of an hour, or even less 
time. At one moment the acute maniac is anxious to embrace 
all who come within his reach, or some particular person 
whom he mistakes for a woman he loves ; while during the 
next instant he is cursing and reviling the whole world, utter- 
ing the most astonishing tissue of obscenity and abuse, shak- 
ing his fists at real and imaginary persons, making the most 
horrible grimaces, and ready to attack with fury any one 
upon whom he can lay his hands. The emotion of anger is 
particularly easy to be aroused in those affected with acute 
mania. The mere act of addressing a word or two to them 
is often sufficient to excite it. They take the most violent 
prejudices against some particular person, and will resort to 
all kinds of deceit and cunning in order to do their imaginary 
enemy an injury. 

While the subject of acute mania may be laughing one 
moment, and shedding bitter tears the next, it is generally 
the case that there is a decided predominance of either the 
gay or . sorrowful emotions, and hence a particular cast is 
given to the tone of the patient. Probably the latter cate- 
gory is more frequently in the ascendent. It is rare to see a 
patient affected with the disease in question whose illusions, 
hallucinations, and delusions, and, as a consequence, his emo- 
tions, are always of a cheerful or pleasurable character. 



ACUTE MANIA. 545 

The will exhibits weakness from the very inception of the 
disorder, though at times there may be for a short period an 
exacerbation of volitional power. A sustained effort of the 
will is, however, impossible with the acute maniac. Occa- 
sionally he is seen to be evidently making an exertion to re- 
strain the excitement of mind and body which exists, or even 
to conceal the fact that he has false perceptions or false be- 
liefs ; but the power can only be exercised for a short time. 

The physical symptoms of acute mania are equally as strik- 
ing as the mental. In the first place, the countenance is per- 
ceived to have undergone a change. The face is generally, 
though not always, heightened in color ; the eyes are often 
bloodshot and preternaturally bright, and are in almost per- 
petual motion. The pupils are exceedingly sensitive to light 
and darkness, and are often perceived to contract* and dilate, 
apparently under the influence of some thought or perception. 
Strong light appears to be painful. Ophthalmoscopic exami- 
nation generally shows the vessels of the retina and choroid 
to be enlarged and tortuous, and the optic disk to be in a 
hypersemic condition. The hair is in disorder, and often 
possesses a peculiar electrical quality, which causes it to 
stand erect like that of a person on the insulated stool of 
a statical electrical machine. The expression is variable, in 
accordance with the ideas and emotions which influence the 
patient ; but there are an exaggerated degree of motility in the 
muscles of the face and an increased power of causing them 
to respond to the thoughts and feelings which are not pos- 
sessed by him in his normal state. To these phenomena must 
be added the disorder of dress which is so generally exhibited. 
The clothes are put on without any regard for appearances, 
and are misplaced, torn, and made dirty, with a thorough dis- 
regard of the proprieties of life. One patient will tie his hat 
over his shoulders ; another puts his coat on hind part before, 
or uses his trousers for a coat ; and another puts her stockings 
over her hands, and struts about in them as if they were gloves. 

The muscular activity of the patient never seems to be 
exhausted. Often, for day after day and night after night, 
he is in a continual state of excitement and motility. His 
arms are gesticulating violently ; he walks, runs, jumps, rolls 
over the floor, dances, and twists and turns his body into 
every possible shape. At the same time he is rarely silent ; 
he talks at the top of his voice one moment, whispers in a low 

35 



546 DESCRIPTION AND TREATMENT OF INSANITY. 

tone the next, and then shouts, yells, langhs, sings, prays, 
curses, and howls, till the room in which he is seems like a 
pandemonium. With all this, there is rarely any marked 
disturbance of the pulse or respiration other than what 
would be caused in any one indulging in the violent and in- 
cessant movements peculiar to acute maniacs. Neither is 
there any elevation of temperature. There may be subjective 
sensations of heat in the skin and other parts of the body, 
but there is certainly no increase of temperature determinate 
by the thermometer or by Lombard's thermo-electric calori- 
meter. 

The digestion is almost invariably impaired throughout 
the whole course of the attack. The appetite is capricious, 
the tongue coated, the bowels obstinately constipated. The 
saliva is generally thick, viscid, and reduced in quantity. 

The urine does not usually show any increase or diminu- 
tion in the amount excreted, but there is almost always a 
large increase in the proportion of phosphates eliminated. 
In some cases the quantity of urea is increased. 

Menstruation is deranged, either by becoming irregular 
or undergoing entire suppression. 

Pregnancy, if existing at the time of an attack of acute 
mania, is rarely modified thereby, the process going on to full 
development. Of course, accidents, such as blows or falls, 
may produce miscarriage ; but even these factors do not seem 
to act with as much force as in sane women. 

It sometimes happens that acute maniacs (though general 
paralytics are more liable to the condition), while in insane 
asylums, get their ribs broken, or, at least, are found with 
their bones fractured soon after their admission into such in- 
stitutions. It is a question whether the condition is due to 
excessive fragility of the bones, rendering them liable to be 
broken on the application of very slight force, or whether it 
is the result of severe blows or pressure received previous to 
or after the admission into the hospital. It has been asserted 
that the injury is the result of pressure applied by the knees 
of hospital attendants to the lunatic while in a recumbent 
position, or to the blows received in his contests with other 
patients. 

It is probable that the truth is to be found in all these 
alleged causes. Fractures of the ribs in the insane rarely 
attract the attention of the subject himself, and are not likely, 



ACUTE MANIA. 547 

in the absence of evidences of suffering, to be noticed by the 
physicians or attendants of asylums. Thus, Dr. Lander Lind- 
say ' states that he has known almost all the ribs of a young 
man's side to be broken without there being any outward 
indication or the exhibition of any kind of symptom. No 
complaint ever emanated from the patient. There was no 
bruise-mark, no lung symptom, no indication of the slightest 
suffering, from first to last ; nor was it ever discovered how 
the injury was inflicted. The patient never could comprehend 
why he was confined to bed and swathed in flannel. Dr. Lind- 
say quotes Dr. Workman, of Toronto, to the effect that two 
cases of acute mania came under his observation in which 
five and seven ribs, respectively, were fractured. In these 
cases the fractures must have existed prior to admission, and 
they would not have been known without post-mortem ex- 
amination. 

At the same time, it cannot be successfully denied that 
these fractures often occur within the walls of asylums by 
violence applied by attendants or patients. Doubtless attend- 
ants are sometimes unjustly accused, but the discipline that 
admits of such an act on the part of a patient as that described 
by Dr. Rogers, 3 superintendent of the asylum at Rainhill, 
England, cannot be very strict. In this case a patient was 
found with broken ribs — u one or more." He accused an at- 
tendant of having knocked him down and kicked him, but 
afterward told a different story, and, on further inquiry, an- 
other patient said "he wanted to come into my ward to build 
a chimney six miles high, and I pushed him down stairs." 

But in the same number of the journal from which this ac- 
count is quoted is a statement from the editor, Dr. Maudsley, 8 
which goes to show that the asylum attendants are not always 
the angelic creatures they are sometimes asserted to be. Speak- 
ing of fractured ribs in lunatics, he says : 

"These injuries of patients are so uniform in character 
that it is clear they must arise from a uniform cause. In 
both these instances the commissioners were told of falls re- 
ceived by the deceased. "We are not of those who believe that 
symmetrical fractures of three or four ribs on either side of 
the sternum can by any possibility arise from any fall which 

1 "Mollities Ossium in Relation to Rib-Fracture among the Insane," Edin- 
burgh Medical Journal, November, 1870, p. 444. 

2 Journal of Mental Science, July, 1880, p. 253. 8 Op. cit., p. 252. 



5±S DESCRIPTION AND TREATMENT OF INSANITY. 

produces fracture of no other bones, and often no external 
bruises. How, then, are they caused % We cannot help think- 
ing that they are sometimes due to the violence of attendants, 
and that they happen in this manner : A patient is refractory, 
or in some way or other comes into collision with an attend- 
ant or attendants. The latter resort to the expedient of 
' downing ' the offender — that is, throwing him down and hold- 
ing him on his back till he promises to do what is required 
of him. If the patient resists, and the attendant is alone, 
the latter may have to exert great force to keep the other on 
his back. Possibly he may have heard of the great power 
of the chest to withstand pressure, of enormous stones being 
broken upon it with hammers, and so forth ; more frequently, 
however, in blind, stupid ignorance, he presses or kneels upon 
the front of the chest to prevent the patient rising. Now, so 
long as the latter can keep his lungs inflated, and his ribs ex- 
panded, he may, if not a very enfeebled person, withstand a 
very great pressure ; but there comes a time when he empties 
his chest, his lungs collapse, and the front of his thorax is 
stove in. Of course, this is more likely to happen as age ad- 
vances and the ribs are less elastic and yielding, but we think 
the force applied must often have been sufficient to break the 
ribs of any person, old or young." 

It appears to be probable that in some cases at least there 
is an abnormal degree of fragility of the ribs in insane per- 
sons. Dr. Hearder * found this condition to exist in eleven 
cases of twenty autopsies made at the Carmarthen County 
Asylum in 1870. He thinks that the fractures of those bones 
which occur in asylums are only rarely to be ascribed to ill 
treatment on the part of the attendants. 

Professor Guddur, 2 of one hundred autopsies — fifty of men 
and fifty of women — found sixteen cases of broken ribs, of 
which only two were in women. These fractures are usually 
first discovered at the autopsy, and then in most cases they 
are old. He thinks they are caused by the patients running or 
falling against something — but none such have come under his 
observation — by the patients injuring each other, or by the 
ill treatment of attendants. And he says, in conclusion, that 
the more intelligent, attentive, and gentle the guardians, and 

1 Journal of Mental Science, January, 1871. 

2 " Archiv fur Psychiatrie," Bd. ii, Heft 3; and " Psychiatrisches Oentral- 
blatt," February, 1871. 



ACUTE MANIA. 549 

the more absolute their control and the less they resort to 
force, the fewer rib-fractures there will be. 

Laudahn 1 has adduced the case of a maniac in whom 
there was a separation of several of the ribs from the car- 
tilages, and who, after his cure, declared that he never re- 
ceived any injury ; but certainly one case proves very little, 
even if we admit the validity of the testimony. In the case 
cited, under the head of chronic intellectual mania, in which 
ribs were broken by the patient falling in the dark over a 
chair, there was no suspicion of any special fragility of these 
bones existing. 

Among the subjects of acute mania no somatic symptom is 
more notable or of more importance than the obstinate wake- 
fulness so generally present. It is the condition of all others 
which most effectually tends to produce exhaustion and 
death, and it is generally of so obstinate a character as to 
resist all ordinary means of relief. It is one of the chief phe- 
nomena to which the attention of the physician should be di- 
rected, for, if sound and refreshing sleep can be obtained, the 
prospect of an entirely favorable termination of the attack 
is very much increased. It is to be borne in mind that the 
same pathological condition of the brain which produces the 
maniacal paroxysm is that also which causes the insomnia. 

The ordinary sleep of the acute maniac is seldom undis- 
turbed by dreams. The muscular actions, the cries, the 
words spoken, the sudden awaking in terror — all go to show 
that his dreams are of a character with his illusions and hal- 
lucinations when awake. Such sleep as this can be of very 
little service in securing rest and the recuperation of the 
hardly-tasked nervous system of the patient. 

The Tidbits of acute maniacs as regards the care of their 
persons and attention to the ordinary rules of modesty and 
decency are often radically changed. In addition to the use 
of profane and obscene language, there is a proneness, even in 
those who have been remarkable during their sanity for a 
strict observance of all social requirements, to indulge in in- 
decent conduct, and to be guilty of acts which are the very 
quintessence of filthiness. Exposing the person, lascivious 
gestures, urinating and defecating in presence of others with- 
out the slightest sense of shame, smearing themselves with 
urine and fseces, and even drinking the one and eating the 

1 " Archiv fur Psychiatric," Heft 1, 1872. 



550 DESCRIPTION AND TREATMENT OF INSANITY. 

other, are acts from which they not only do not shrink, but 
which they commit with pleasure and bravado. I have 
known a refined and educated woman, in an accession of 
acute mania, to bedaub her face and hair with her own 
ordure. In this case, however, the act was committed under 
the illusion and delusion that she was anointing herself with 
a holy oil which was to save her soul from eternal punish- 
ment. In other instances such performances are the result 
of a spirit of mischief and opposition, the patient knowing 
perfectly well the nature of the act he is perpetrating, and 
taking exquisite delight in the trouble and disgust he is ex- 
citing. Coprophagy is more common with chronic dements 
than with other classes of lunatics, and will be considered 
further under another head. 

Loquacity and incoherence are almost constant symptoms 
in cases of acute mania. The disposition to talk is uncon- 
querable, and words are poured forth in a constant stream of 
incoherence. It seems to make no difference to the maniac 
what he says, or whether he is listened to. If there is no one 
to hear him, he talks to himself, or to the images his deranged 
perceptions have brought up before him. 

There is both incoherence of words and of ideas. The 
thoughts follow each other so rapidly that the speech cannot 
express them before others, crowding in, stop the articulation 
in one direction to direct it to another. 

Frenzy or fury is a condition liable to occur during at- 
tacks of acute mania, and consists in an exaltation of the ex- 
citement, both mental and physical, under which the patient 
labors. In this state the subject is especially dangerous, and 
is constantly making attempts to commit acts of violence. If 
unrestrained, several murders may be committed, either as a 
consequence of the ungovernable rage which exists, or as the 
result of some delusion which, for the time being, is in the 
ascendant. 

A patient, for instance, will have been suffering for several 
days or weeks from an ordinary attack of acute mania of no 
very severe type, when suddenly, without previous warning 
of any kind, the paroxysm of fury occurs. The face becomes 
redder, the eyes glisten with excitement, the actions become 
more violent, and, if allowed, a murder, or a series of murders, 
may be committed, all of the most horrible description, and 
perpetrated with an astonishing degree of violence. 



ACUTE MANIA. 551 

Such is a description of acute mania in its typical form. 
Of course, there are many cases which vary more or less from 
the category of symptoms presented, but the differences are 
in no respect essential. At the same time there may be pres- 
ent in the affected individual some pre-existing condition 
which modifies the course of the disease either by rendering 
it milder or severer, or by adding to it features of a specific 
character. Thus, sometimes there is a decided predominance 
of good humor and gayety. The patient is in a constant state 
of hilarity. He dances, sings, laughs, plays tricks of various 
kinds, brags of his strength, and other qualities, but rarely 
passes the bounds of probability, in this respect presenting a 
marked contrast with the general paralytic. 

Or the attack may assume a religious, erotic, or other 
emotional type, and the actions, language, illusions, halluci- 
nations, and delusions are in harmony therewith. These types 
of acute mania are very different from the emotional mono- 
manias to which attention has been directed. 

But there is a well-marked variety of acute mania which 
has been at times confounded with an emotional monomania, 
and that is the form known as satyriasis in the male, and 
nymphomania in the female, and which some authors have 
failed to distinguish from erotomania. In the latter disorder 
there is no obvious excitation of the sexual appetite, however 
much the instinct in question may be the substratum of the 
mental derangement. It is the emotion of love which is 
exalted, and not the genesic appetite, which, so far from being 
obtrusively manifested, is effectually kept in entire subjection 
to the intellect and the will. 

But in satyriasis and nymphomania it is the sexual ap- 
petite that governs, and which puts its impress upon the char- 
acter of the sensorial derangement, the delusions, the lan- 
guage, the acts, and other phenomena. There is in either 
sex an intense and irrepressible desire for sexual intercourse, 
and for indulgence in lascivious conduct. The speech is ob- 
scene, the gestures are suggestive of what is passing in the 
patient's mind, and indecent advances are shamefully made 
to all of the opposite sex who come within reach. With 
these symptoms there are heat and a sense of irritation in the 
genital organs, which of themselves prompt to frequent acts 
of masturbation. 

In men the venereal excitement may run so high that 



552 DESCRIPTION AND TREATMENT OF INSANITY. 

rape and murder are perpetrated, while in women there are 
spasmodic movements, followed by the sexual orgasm and 
ecstatic or epileptiform convulsions at the mere sight of a 
man. It is not at all uncommon for the act of masturbation 
to be performed by friction of the genital organs against the 
bed or some article of furniture, the clothes, or by voluntary 
contractions of certain muscles of the body. I have known a 
female patient, the subject of nymphomania, to bring on the 
sexual orgasm, in spite of all means to prevent it, by what 
appeared to be contractions of the gluteal, the constrictor- 
vagina3, and the compressor-urethra? muscles. 

Nymphomania, as a type of acute mania, is more common 
than satyriasis, for the reason, probably, that women have 
fewer opportunities than men for the gratification of their 
sexual desires. 

There are other forms of genesic aberration still more de- 
grading in their manifestations, entirely independent of acute 
mania, and which do not, therefore, now require our attention. 

Acute mania exhibits a tendency to run a certain definite 
course, which, however, is not limited as to duration. Some 
cases last a few weeks, others a few months, and others per- 
haps a year. Rarely does the affection extend in its original 
form beyond this last-named period. Its average duration is 
about three months. In the course of the attack there are 
remissions in its violence, which are followed by periods of 
increased excitability. In favorable cases, after a time there 
is a gradual abatement in the intensity of the phenomena, the 
patient begins to sleep better, illusions and hallucinations be- 
come less frequent, and are not of so decided a character, and 
the delusions are not held with the same tenacity as formerly. 

Again, the case may terminate in dementia, or in chronic 
intellectual mania, which in their turn may end in complete 
recovery ; or, 

Again, the patient may die from acute inflammation of the 
brain or its membranes, from some other organic cerebral le- 
sion, or from exhaustion of the system. 

The prognosis in ordinary cases of acute mania is rather 
favorable than otherwise. The factors which militate against 
recovery are a feeble state of the system generally, the circum- 
stance of the attack not being the first, and the existence of a 
strong hereditary tendency to insanity. 



PERIODICAL INSANITY. 553 

b — PERIODICAL INSANITY. 

By periodical insanity, or recurrent insanity, as it has also 
been called, is to be understood mental derangement gener- 
erally in the form of acute mania of a more or less severe 
type, occurring at stated periods, which are generally alike 
for each individual. It does not comprehend those cases 
of lunacy of any form in which there are remissions or 
even intermissions in the violence of the symptoms, some 
phenomena still remaining. It applies only to those in- 
stances in which all the manifestations of a disordered mind 
have disappeared, and in which, consequently, the patient is 
to all intents and purposes sane, able to attend to his affairs, 
and to conduct himself after his normal manner. In those 
cases in which the intervals of apparent sanity are very 
short, such as a few hours, close examination will almost 
always, if not invariably, show that some evidences of men- 
tal derangement still remain, and that the phenomenon is a 
remission only. 

Periodical insanity is, therefore, a distinct variety of men- 
tal aberration, the characteristic feature of which is a disap- 
pearance of all the symptoms, their return in the same form 
at some subsequent period, and their continuance for the 
same length of time, as in the first instance. This sequence 
may be repeated for many years. 

In a case of periodical insanity occurring in a lady of this 
city, the accessions, which are those of acute mania, last only 
eight days. On the ninth day she is entirely sane in every 
respect, with a somewhat indistinct remembrance of the symp- 
toms she has experienced. In exactly three months from 
these cessations she is again attacked. The illusions, hallu- 
cinations, and delusions characteristic of each accession are 
by no means alike, though there is a degree of similarity in 
them all. Thus her sensorial aberrations, always relate to 
dead people, but not to the same persons. During one par- 
oxysm she will see no other forms than those of little chil- 
dren which are laid out in their coffins, or being borne 
through the air by angels, or which entirely surround her in all 
positions as she walks the floor of her apartment, or lies down 
in her bed. Her conversation is entirely in regard to these 
infantile corpses, which she identifies as the Princes in the 
Tower, or the children of John Rogers the Smithfield martyr, 



554: DESCRIPTION AND TREATMENT OF INSANITY. 

or some other infants or yonng persons of whom she has read 
or heard. 

Again, her hallucinations will consist of dead Indians. 
Powhatan, Pocahontas, King Philip, Tecumseh, Red Jacket, 
Black Hawk, Billy Bowlegs, Sitting Bull, and other defunct 
aborigines are grouped about and talk with her. Occasionally 
she will have illusions that persons about her are among the 
dead persons she sees and talks with, but these are not com- 
mon, hallucinations greatly predominating. 

Though she has been affected for about twelve years, and 
in that time has had nearly fifty recurrences, she has never 
had the same set of hallucinations more than once. The last 
that I have been informed of consisted of the dead Presidents 
of the United States. 

All her dead visitants are not present at the same time. 
She talks with the utmost volubility, and expresses wonder 
why this or the other has not yet made his appearance. Some 
she lauds to the skies, others she abuses in very profane lan- 
guage, and on several occasions the images have not, so far as 
could be judged by her conversation, presented an entirely 
decorous appearance. Two or three times she has manifested 
slight sexual excitement in regard to some of her corpses. 

There is no very great degree of motorial agitation. Her 
sleep would be bad if it were not systematically procured by 
the administration of morphia, chloral, or the bromides. 

There is no derangement of the menstrual function ; neither 
do the attacks apparently have any connection with the men- 
strual periods. 

Another case was that of a gentleman, aged thirty -five, 
who, about the first week in January of each year, was seized 
with a paroxysm of acute mania, during which there were 
strong suicidal tendencies. Knowing the certainty of the re- 
currence of the paroxysm, he was accustomed to place him- 
self in the care of a medical friend till the seizure, which 
lasted about three weeks, had passed off. He was then per- 
fectly sane in every respect — perceptionally, intellectually, 
emotionally, and volitionally — and able to transact with 
marked ability and success the very extensive mercantile 
operations which he carried on. This gentleman has been 
cured by the administration of the bromide of sodium con- 
tinuously during the intervals of the attacks, having had no 
seizure now for several years. 



PERIODICAL INSANITY. 555 

The particulars of a case were given by Mr. G. P. Avery, 
at the February, 1883, meeting of the Society of Medical 
Jurisprudence, in which an individual of his acquaintance 
was affected with a paroxysm of acute mania at the time 
of each presidential election. The attacks were particularly 
characterized by the existence of the delusion that he was 
elected President of the United States. He proceeded to 
appoint his cabinet, and to assume other functions of the 
presidential office. Each attack lasted about a month, and 
then he was perfectly sane till the next election, four years 
afterward, when another paroxysm ensued. 

Such cases cannot be regarded as lending any support to 
the doctrine of lucid intervals, and which has been discussed 
in a previous chapter of this work. During the so-called 
lucid interval, it may be repeated that the patient is not en- 
tirely free from symptoms of insanity. He is simply passing 
through a remission, and very slight causes may be sufficient 
to reawaken the phenomena in all their original intensity. 
But in periodical insanity the case is different. Here the 
attack runs its course and disappears, leaving the patient free 
from disease ; and yet it seems a difficult matter for some 
alienists to distinguish between such a form of insanity and 
these very common occurrences in all varieties of mental aber- 
ration — remissions. This is the case with Koster, 1 who sees 
periodicity not only in every case of insanity, but in every 
other phenomenon of nature, and who attributes it to the 
influence of the sun and moon, acting in a manner similar to 
the exercise of their power over the water of the ocean, as 
well as to the magnetism of the earth. However efficient these 
and other factors may be in producing remissions and exacer- 
bations in attacks of ordinary insanity, it is not at all proba- 
ble that they have the slightest influence in periodical mania, 
in which the interval of sanity is sometimes several years. 

Billod 2 makes the proper distinction between the two con- 
ditions, and clearly recognizes the existence of periodical in- 
sanity of the form now under notice. Thus, he says : 

"I have, in the asylum of Sainte-Gemmes, several maniacs 
who, during the thirteen years that I have been at the head 

1 " Ueber die Gesetze der periodischen Irreseins und verwandter Nervenzu- 
stande," Bonn, 1882. 

3 " Considerations m6dico-16gales sur les intervalles dits lucides chez les 
alienes," Des maladies mentales et nerveuses, Paris, 1882, t. i, p. 416. 



556 DESCRIPTION AND TREATMENT OF INSANITY. 

of the institution, have presented successions of paroxysms 
with intermissions of from one to two years. I can specially 
cite the case of a priest who, during his intermissions, is suf- 
ficiently lucid to perform the duties of the ministry and to 
fill the office of second chaplain without the fact of his suc- 
cessive paroxysms impairing in the least his ecclesiastical 
prestige. This is somewhat remarkable, for his audience are 
aware of his history, and have seen him stark naked during 
the height of his delirium. Now, when an individual remains 
a sufficiently long time without exhibiting the least sign of 
mental aberration, can it be said that he is in a lucid inter- 
val ? No one, I think, can properly hold such an opinion. He 
is, during that period, no longer a lunatic, and the accession, 
when it returns, should be regarded as a recurrence. Its ter- 
mination has all the characteristics of a cure, during the du- 
ration of which sequestration and isolation should, to a certain 
point, cease to be necessary ; and, that during which, also, the 
patient's acts should be regarded as rational — such, for instance, 
as making a valid will — seems to me to be unquestionable." 

Distinct periodicity is seen, also, in many cases of emo- 
tional and volitional morbid impulses — such as suicidal and 
homicidal mania, pyromania, kleptomania, and the like, in 
which, in the intervals between the attacks, the subject is in 
his normal state of sanity. 

C — HEBEPHRENIA. 

Hebephrenia ("Hftrj, puberty, and $pr)v, (frprjviTTs, the mind, 
frenzy) is the term applied to the insanity of pubescence, a 
form of mental derangement which presents many character- 
istic features, and which, as the name implies, is peculiar to 
that period in both sexes when the organism is undergoing 
the changes incident to its full development. 

That there is such a type of insanity has long been known, 
but it is only within recent years that it has formed the sub- 
ject of special study, and this has been heretofore to a very 
limited extent. The only monographs upon the affection 
with which I am acquainted are those of Hecker 1 and of 
Fink, 3 with whose description no inconsiderable experience 
enables me to agree in all essential particulars. 

1 "Die Hebephrenia" Virchow's arcMv^ B. lii, 1871, p. 394. 

2 "Beitrage zur Kenntniss der Hebephrenic," Allegemeine Zeitschrift far 
Psychiatrie, 1880. 



HEBEPHRENIA. 557 

The disease in the beginning is manifested chiefly in the 
emotional part of the mind. The subject becomes depressed 
in spirits, sometimes to such an extent as to cause more or 
less well-directed attempts at suicide. There appears to be 
a settled conviction that the efforts which are being made to 
perform the duties or tasks which have been assigned are not 
adequately appreciated, and that, no matter how faithfully 
labor may be performed, it will result in no personal advan- 
tage. The future, therefore, appears dark and forbidding, 
and the element of hope, of such vast importance as an incen- 
tive to youthful minds, is gradually eliminated from the men- 
tal organism of the boy or girl, as the case may be. 

Of course, this is all morbid, but it is none the less real. 
Appearing at first as a mere apprehension or fear, it grad- 
ually increases till it becomes a predominating influence. 
The subjects feel that they are not understood, they misinter- 
pret the actions of those around them, they become suspi- 
cious of those with whom they have heretofore associated, 
and whom they have regarded as their best friends, and they 
become not only the enemies of those with whom they have 
had direct associations, but of the whole human race. 

It is not long before there is a marked deterioration in 
their moral qualities. Conceiving as they do that fair and 
honest dealing will avail them nothing, but, on the contrary, 
will be employed to their disadvantage, they do not hesitate 
to lie, to cheat, to steal, and to resort to all kinds of deceit 
and subterfuge to accomplish any object they may have in 
view. "It would have been no use," said a boy of fifteen to 
me, after he had run away from school with money and other 
things which did not belong to him, " for me to have asked 
the principal for money, and to let me go home, as I was ill. 
He would have refused, and have punished me besides. So 
I just took what I could lay my hands on and went off in the 
night when they were all asleep. You may send me back, 
but I'll run away again the first chance I get. Everybody is 
down on me there. If I learn all my lessons they find fault 
with me, and if I don't learn them it's no worse ; so what's the 
use ? Send me back, but the next time I run away I won't 
come home, and you won't find me either." 

It is rarely the case that at this time the condition of the 
subject of hebephrenia is taken at its real value. The pecul- 
iarities of character and disposition which are being devel- 



558 DESCRIPTION AND TREATMENT OF INSANITY. 

oped are generally regarded as so many evidences of wicked- 
ness, to be treated with severity, or perhaps to be let alone, 
as beyond cure by moral regimen. Schools get rid of such 
pupils as the one above referred to, and very properly, for 
their example is decidedly pernicious, and parents, not know- 
ing what to do with them, put them, if pecuniarily able, un- 
der the charge of a tutor, with instructions to eradicate, by 
some process which the tutor is supposed to know, the evil 
propensities which in some way or other have been con- 
tracted, or they send them to another school, from which they 
either soon elope or are expelled, or they are kept at home 
to do nothing, but to remain apt subjects for the future de- 
velopment of the disease. 

In any event this development is sure to come. Delusions 
of various kinds begin to make their appearance, and these 
are formed not from illusions or hallucinations which are never 
present in the inception of the disorder, but out of the mor- 
bid thoughts of the subjects themselves, and are almost in- 
variably of an intensely selfish character. Thus, a young 
woman, seventeen years of age, who came to my clinique at 
the Bellevue Hospital Medical College, and who had several 
times run away from home, and been brought back by the 
police, had the idea that she had been specially endowed by 
the Virgin Mary with the ability to read the thoughts of 
people in any part of the world. Her father was a sailor, and 
was absent from home, and she was continually reminding 
her mother of what he was thinking at any particular mo- 
ment ; and these thoughts were always of her, and of the deep 
pain he felt at the idea of the bad manner in which she was 
treated. On one occasion she went suddenly into the kitchen 
and threw the dinner into the fire, saying that her father 
thought it was not good enough for her to eat. Again she 
picked a mattress to pieces, because her father thought it 
was not soft enough for her to sleep on ; and on still another 
occasion she threw all the crockery out of the window and 
broke the furniture, because, as she said, her father thought 
she ought to eat out of silver and use mahogany chairs and 
tables. Finally, intelligence was received of the death of her 
father, when she laughed, and said she had known all along 
he was not coming home, but that instead of being dead he 
had married another woman in Lisbon, and had taken her to 
the East Indies. Soon after this she went before a police 



HEBEPHRENIA. 559 

magistrate and made oath that her mother had beaten her 
severely, showing some bruises which she had received by a 
fall on the ice, and returned home with a policeman armed 
with a warrant for her mother's arrest. In this case mastur- 
bation was verified. The disease went on unchecked, and the 
patient is now in a state of hopeless dementia. 

In addition to the involvement of the intellect as regards 
false conceptions, there is always a marked deterioration of 
the force of the mind. The power of concentrating the atten- 
tion is diminished, sustained thought upon any one subject 
becomes impossible, and the ability to comprehend is greatly 
impaired. The facial expression exhibits the mental weak- 
ness of the patient, and there are frequent paroxysms of silly 
laughing, the reason for which is never given. Accessions of 
acute mania are not at all uncommon at this period, and then 
illusions and hallucinations are formed. In a young gentle- 
man, the subject of hebephrenia, whom I saw in consultation 
with Dr. Kittredge, of Fishkill, and who had several times 
run away from home, there were almost constant hallucina- 
tions of hearing and paroxysms of imbecile laughing. He 
had had several attacks of acute mania. In another, whom 
several years ago I committed to Dr. Kittredge' s asylum, there 
were similar phenomena, conjoined with well-marked system- 
atized delusions. 

These symptoms may exist for several years before the 
passage of the affection into the stage of dementia ensues. 
Sooner or later, however, this is the termination. 

Probably hebephrenia is equally common to the two sexes, 
although Fink ' restricts it entirely to males. It appears to be 
induced by any cause capable of lessening the vital powers 
of the individual, among which masturbation and also the in- 
ception of the menstrual function are preeminent. One of 
the worst cases I v ever saw occurred in a boy of sixteen, from 
South America, and was the result of excessive masturbation. 
I sent him to Dr. Parsons, at Sing Sing, and it was found 
necessary to watch him night and day without intermission, 
to prevent the act of onanism. The case was in aU respects 
a typical one of hebephrenia. Several months had elapsed 
when the patient first came under my observation ; there were 
then illusions and hallucinations, there had been several acute 

lu Beitrage sur Kenntniss der Hebephrenic, " Allegemeine Zeitschrift fur 
Psychiatrie, 1880. 



560 DESCRIPTION AND TREATMENT OF INSANITY. 

maniacal attacks, and there was the characteristic tendency 
so frequently observed, to run away. The favorable result 
obtained by Dr. Parsons's care goes far to lessen the force 
of the gloomy prognosis usually expressed in regard to the 
affection. 

Undoubtedly masturbation when practised to excess may 
modify to a greater or less extent the symptoms of hebe- 
phrenia, but the product is not entitled to be considered a 
separate form of mental derangement. The insanity of mas- 
turbation is simply hebephrenia, with the additional phenom- 
ena due to excessive onanism. Just as we meet with the 
peculiar condition produced by this vice without there being 
hebephrenia, so we encounter the latter affection when there 
is no reason to suspect masturbation. Nevertheless, the con- 
nection is an important one, and ought not to escape the atten- 
tion of the physician. The influence of masturbation in caus- 
ing insanity has been known from the earliest period, but the 
relation has never been so graphically set forth as by Dr. Lu- 
ther Bell, 1 of the McLean Asylum in Massachusetts, who pub- 
lished his observations nearly forty years ago. It has also 
been described by Schroeder van der Kolk, 2 but many au- 
thors, as for instance Ellis, 3 fail to discriminate between cause 
and effect in their remarks on the relation of onanism with 
insanity. Nothing is more common than for lunatics of all 
types to practice masturbation, and doubtless the vice pro- 
duces modifications in the physical and mental condition of 
the patient. 

Hebephrenia is most apt to make its appearance, not at the 
very beginning of puberty, but a year or two afterward, when 
the system is experiencing to the utmost the demands made 
upon it. Hereditary influence is certainly a strong predis- 
posing factor in its etiology. 

d — CIRCULAR INSANITY. 

By circular insanity {folie circulaire, Falret ; folie d dou- 
ble forme, Baillarger) is to be understood a variety of mental 
alienation characterized by alternations of depression and ex- 

1 " Annual Report of the McLean Asylum," 1844. 

2 " The Physiology and Pathology of Mental Diseases," RudalFs translation, 
London, 1870, p. 139. 

3 " A Treatise on the Nature, Symptoms, Causes, and Treatment of Insanity," 
London, 1838. 



CIRCULAR INSAOTTY. 561 

citement, each period being entirely distinct one from the 
other. 

Two forms of the affection are recognized. In the one, 
there are periods of sanity between the accessions ; in the 
other, the stages of depression and excitement alternate con- 
tinuously without intermission. 

The fact that attacks of melancholia were sometimes suc- 
ceeded by paroxysms of mania with mental exaltation has 
been noticed by many writers, but no one, before Baillarger ' 
published his first memoir on the subject, gave it the attention 
it deserved. He was followed almost immediately and appar- 
ently independently, by Falret, 2 to whom we owe the term 
folie circulaire, or circular insanity. Since then the affection 
has been studied by alienists in all parts of the world, but by 
none so thoroughly as by those of France. 

Baillarger's paper is based on six cases, and as the results 
of their study he arrives at the following conclusions : 

" 1. Besides monomania, melancholia, and mania, there ex- 
ists a special variety of insanity characterized by two regular 
periods, the one depression, the other excitation. 

"2. This species of insanity may appear, a, as an isolated 
accession ; 5, the seizures following each other in an intermit- 
tent manner ; c, occurring without intervals between the par- 
oxysms. 

" 3. The duration of an accession varies from two days to 
a year. 

" 4. When the accessions are short, the transition from the 
first to the second period is sudden, and ordinarily takes place 
during sleep. It is effected gradually, however, when the ac- 
cessions are prolonged. 

" 5. In this last case the patients seem to pass into a stage 
of convalescence at the end of the first period ; but if the re- 
turn to health is not complete after fifteen days, a month, or 
six weeks at most, the second period is developed." 

It is thus seen that Baillarger recognizes three varieties of 
circular insanity, while Falret 8 describes but one, the second 

x " Note sur un genre de folie dont les acces sont caracterises par deux peri- 
odes regulieres, Tune de depression et l'autre de Fexcitation," Bulletin de Vaca- 
demie imperiale de rnedecin, t. xix, p. 340, 1853-54. 

3 "Lecons cliniques de rnedecin mentale," Ire partie, Paris, 1854, p. 219. 

3 "Memoire sur la folie circulaire," etc., Bulletin de Vacademie imperiale de 
rnedecin, t. xix, 1853-'54, p. 382. 
36 



562 DESCRIPTION AND TREATMENT OF INSANITY. 

of Baillarger, in which there is a distinct interval between the 
accessions. 

Among German authors, circular insanity has been recog- 
nized as a distinct affection of the periodical class by Kirn, 1 
who designates it die cyclysche Psy chose ; Kraft-Ebing, 2 das 
circular e Irresein ; and Koster, 3 per iodischen Manie abwecli- 
selnd mit Melancholic In this country the only alienist who 
has alluded to it is Spitzka, 4 who has given a short but accu- 
rate description of the affection. 

Period of Depression. — The period of depression by which 
the first stage of circular insanity is characterized may con- 
sist of simple melancholia without delirium or illusions, 
hallucinations or delusions. The patient is indisposed to 
either physical or mental exertion, he shuns the compan- 
ionship of others, is averse to speaking, frequently remain- 
ing silent for hours, and if forced to respond to questions 
put to him does so in the fewest possible words, and with- 
out change of countenance. Again, he talks at times volu- 
bly enough, but his conversation is entirely in regard to 
himself, of his horrible feelings, his despair, his weariness 
of life, and the unhappy hours he passes, his mind filled 
with the most dreadful thoughts of the past, the present, 
and the future. His countenance is a fair reflection of 
the condition of his mind. His eyes are scarcely raised to 
look at those who address him, and the most exciting 
events do not engage his attention. The pupils are dilated, 
the brows contracted, the corners of the mouth drawn down, 
his whole aspect that of a person plunged in the deepest 
sorrow. 

The sentiment of affection for relatives and friends is ut- 
terly extinguished. The only grief he is capable of experi- 
encing is at the contemplation of his own real or imaginary 
sufferings, and yet this does not rise to the highest point, for 
nothing causes the flow of tears or any other violent expres- 
sion of anguish. 

The power of the will appears to be nearly abolished. His 
duties are neglected, for he has not the force to perform them, 
even if he felt the obligation to do so. His business affairs 

1 " Die periodischen Psychosen," Stuttgart, 1878. 

2 " Lehrbuch du Psychiatrie," Stuttgart, 1879-'80. 

8 " Ueber die Gesetze des periodischen Irresein," Bonn, 1882. 
4 New York Medical Gazette, May 9, 1880. 



CIECULAR INSANITY. 563 

no longer interest him, and he views with equal indifference 
large gains or large losses. 

At the same time, the intellect does not escape the general 
hebetude which has overwhelmed the other categories of men- 
tal facilities. The ability to think is markedly impaired. He 
no longer comprehends even simple matters with the quick- 
ness and exactness which formerly characterized him, and his 
ideas rarely extend beyond himself. His habits, which may 
formerly have been cleanly, are now the very reverse of neat- 
ness ; he neglects his person, and, though not actively filthy 
— for to be so would require a degree of physical exertion of 
which he is incapable — he is entirely regardless of those pro- 
prieties of life which are essential to the comfort of sane per- 
sons. 

In addition to the somatic symptoms mentioned, there is 
very generally a decline in the bodily weight ; the head feels 
full, or there is actual pain experienced in this part, and there 
are sometimes attacks of vertigo. The cutaneous sensibility 
is either diminished or augmented or perverted. The sight 
is sometimes indistinct ; there is intolerance of light, and the 
ophthalmoscope shows the optic disks and choroids to be 
abnormally pale, and the vessels of the former to be attenu- 
ated. 

The bowels are usually constipated ; the appetite is abol- 
ished ; food is taken with reluctance, and only when the 
pangs of hunger become unbearable or actual force is used. 
There is stomachal dyspepsia, and large quantities of flatus 
are discharged from the stomach and the intestines. 

The respiration is slow and labored, and the pulse, which 
becomes small and feeble, falls sometimes to fifty, forty, or 
even thirty beats in a minute. Bltti * has noticed a vaso- 
motor disturbance, which has been observed in hysterical 
women, or as an independent affection, and that is a spasm of 
the arteries of the fingers producing the phenomenon known 
as dig it I mortui, and which is characterized by coldness and 
bloodlessness of these members. 

Menstruation is sometimes unaffected, and again ceases 
during the period of depression, to be resumed during the 
period of excitation. 

The ophthalmoscope will show an anaemic state of the 
fundus of the eyes in almost every case. The optic disks are 

1 "Traite clinique de la folie a double forme," Paris, 1883, p. 166. 



564 DESCRIPTION AND TREATMENT OF INSANITY. 

paler than in their natural condition, and the retinal vessels 
are smaller. 

In other cases, the melancholia, instead of being of the 
simple form described, is marked by delirium, by sensorial 
aberrations, and by delusions, constituting essentially the form 
already brought to the attention of the reader, in the previous 
chapter, under the name of melancholia with delirium. 

Ritti, 1 in his admirable work on the disease in question, 
makes four classes of the delirious ideas which are met with 
in this variety of melancholia. 

In the first there is a t&dium mtw, which may reach 
such a degree of intensity as to lead to the development of 
suicidal ideas, and even to attempts at self-destruction. 

In the second class there are conceptions of personal un- 
worthiness, or guilt which is past all pardon, either in this 
world or in that to come. Morbid fears of all kinds may exist, 
mostly concerned with the idea of the " unpardonable sin" 
and eternal damnation. Again, the patients may conceive that 
they have committed sins of various kinds, and that officers 
of justice are in pursuit of them ; or they may think that ex- 
piation is only to be made by self-inflicted suffering, and they 
may accordingly refuse to eat, or may even mutilate them- 
selves in various ways. A patient of my own, who had for 
several years suffered with circular insanity, had, in one of 
his periods of depression, driven nails through his hands and 
feet, under the idea that he should try to become like Christ 
in everything. Sometimes they refuse to speak, and, when 
they do attempt to converse, their language is often incohe- 
rent, although few words are used. Indisposed as are the sub- 
jects of this form of melancholia to physical exertion, they 
sit in one place throughout the day, moving only when com- 
pelled by energetic commands or actual physical force. The 
patient to whom I have just alluded allowed, on one occa- 
sion, the water to flow into the bath-tub till it ran over the 
top and did a great deal of damage, rather than rise from his 
chair and turn it off. 

The third class is characterized by the existence of the 
delirium of persecution, and by the presence of delusions and 
hallucinations in accordance with the delusions. Under the 
idea that the food is poisoned, patients thus affected refuse 
to eat, and forcible feeding has to be resorted to. 

1 Op. cit., p. 62. 



CIECULAK INSANITY. 565 

In the fourth class the melancholia assumes the hypochon- 
driacal type, and the illusions, hallucinations, and delusions 
of the patients relate almost entirely to themselves. 

It is rarely the case that any one of these several forms is 
met with uncombined with some one or more of the others. 

In a third type, which is by no means as common as either 
of the other two, the mental depression is of the form pre- 
viously described under the designation of melancholia with 
stupor. This may be of different degrees of intensity, from the 
simple suspension of some one or more of the faculties of the 
mind, to that in which, conjoined with the torpor of mind and 
body, there are terrifying illusions and hallucinations of sight 
and hearing, apparently threatening the patient with the most 
horrible torments from which he believes it impossible to 
escape. 

In none of the cases of circular insanity which have come 
under my observation were there the cataleptic phenomena 
referred to by Ritti, 1 though I have in two cases witnessed 
symptoms in a measure approaching thereto. 

Period of Excitement. — The period of excitement in cases of 
circular insanity may, like that of depression, be of three dif- 
ferent but analogous varieties. There may be a state of simple 
mental exaltation in which there are neither sensorial nor in- 
tellectual perversions, but in which all the categories of men- 
tal faculties are in a more or less excited condition. The 
ideas flow with rapidity, the emotions which predominate are 
those of a gay character, the language is brilliant and often 
startling in the conceptions which are expressed, and which, 
though possessing these features, does not indicate the exist- 
ence of delusion in the mind of the patient. 

Conjoined with the excess of mental activity there is a cor- 
responding condition of the muscular system. Patients thus 
affected are continually in motion. Rest is as painful to them 
as action is to those who are passing through the stage of de- 
pression. They sleep but little, and yet do not appear to suf- 
fer from insomnia. They never complain. Obstacles are not 
heeded, and if engaged in business they are disposed to ex- 
tend still further their operations, and to plunge into specula- 
tions which prudent persons would be apt to avoid. 

Although there is rarely any incoherence in speech, there 
often is an incoherence of ideas. In fact, these frequently fol- 

1 Op. cit., p. 87. 



566 DESCRIPTION AND TREATMENT OF INSANITY. 

low each other with such rapidity that the speech cannot 
keep up with them, and the individual breaks off in the midst 
of a sentence, to begin another relating to quite a different 
subject.. 

Thus, although the memory participates in the general ex- 
altation of all the mental faculties, and the individual recalls 
with vividness matters that occurred many years before, yet 
the ideas thus evoked come without logical sequence, and are 
thus blended into a confused mass, from which he finds it im- 
possible to disassociate them. Events which happened, for in- 
stance, in his childhood, and which had been long since for- 
gotten, are recalled, but appear as though only a short time 
had elapsed since their occurrence ; while those which took 
place a few months ago appear to be contemporaneous with 
others of his infancy. This inability to obtain a correct idea 
of time in regard to past events is a marked feature of the 
condition under consideration. 

Loquacity is certainly a very characteristic phenomenon of 
the simpler exaltation which often represents the stage of ex- 
citement. There is nothing about which the patient will not 
talk. He recalls whole chapters of the Bible which he learned 
when a boy, declaims the orations which he spoke at school, 
and, if he can recollect nothing, invents discourses for the oc- 
casion. The fact that he knows nothing about a subject is no 
bar to his conversing upon it. He assumes a knowledge, and 
will with the utmost seriousness advance views as being held by 
noted persons who have never expressed an opinion on the mat- 
ter. Strongly impressed with the sense of his individuality, 
the subject of this variety of the period of excitement of cir- 
cular insanity is not to be put down by those with whom he 
comes in conflict. He asserts himself vigorously on all occa- 
sions, and, if unable to carry his point by fair means, does not 
hesitate to lie and cheat to effect his purpose against those 
whom he imagines to be hostile to him, and even against his 
friends he often circulates the most infamous slanders, and 
takes a malicious pleasure in witnessing the pain and confu- 
sion he may have caused. He is, therefore, apt to be con- 
stantly in disputes, and not infrequently has condign pun- 
ishment inflicted upon him by some one who will not tolerate 
his impertinences and his lies, or by the strong arm of the 
law. 

Occasionally excitation or perversion of certain appetites 



CIRCULAR INSANITY. 567 

is observed in this class of patients, and excesses are com- 
mitted which are beyond the limits of propriety or decency. 
Thus, a tendency to the inordinate nse of alcoholic liquors, of 
opium, Indian hemp, and other stimulants and narcotics, may 
be developed in those who at other times do not touch these 
substances. Again, the sexual appetite is increased, and mas- 
turbation, venereal excesses, or unnatural practices, may be 
indulged in to a frightful extent. 

The second form in which the period of excitement may 
be manifested is that of acute mania. Here there are illu- 
sions, hallucinations, delusions, incoherence, and intense men- 
tal and physical exaltation, the condition being such as has 
already been described in a previous section of the present 
chapter. 

■ The third form is that of mania with delirium of grand- 
eur, a state which recalls very forcibly the like condition 
which constitutes so marked a characteristic of general paraly- 
sis. The individual boasts of his great wealth, his immense 
physical strength, his skill in all the arts and sciences ; the 
great works he is about undertaking ; his success in all af- 
fairs of the heart ; his influence with great men ; and so on 
through all possible conceptions of his active mind. There 
is no limit to the powers, the greatness, the proficiency which 
he claims for himself, and no end to the changes which his 
delusions may undergo. 

The physical symptoms of the period of excitement are 
almost as striking as the mental, and are in marked contrast 
with those which were present in the stage of depression. 
The loss of weight, which was then a prominent feature, is 
now arrested, and the body begins to increase sensibly from 
day to day, till it reaches its normal standard. This result is 
due not only to the influence of the changed emotions, but 
also to the improved appetite and powers of digestion. There 
is no longer gastric or intestinal inertness. 

The circulation becomes more active, the pulse not only 
rising in fulness and force, but also in rapidity, reaching 
sometimes to 120 beats a minute. 

Attacks of cerebral congestion are common. They are 
evidenced by vertigo, slight loss of consciousness, and more 
or less severe convulsive twitchings of the limbs, or of individ- 
ual muscles. These seizures are epileptiform in character, 
and occasionally may amount to a fully developed attack of 



568 DESCRIPTION AND TREATMENT OF INSANITY. 

grand mat. Periods of unconsciousness, but with the ability 
to perform voluntary acts, are sometimes met with. There 
may also be aphasia, temporary and localized paralysis, espe- 
cially of the muscles of the eye and face, and sharp par- 
oxysms of pain simulating neuralgia, or the fulgurant pains 
of locomotor ataxia. 

The ophthalmoscope will almost invariably show a con- 
gested condition of the optic disks, enlargement of the retinal 
and choroidal vessels, and increased redness of the choroids. 

These two periods of depression and excitement may fol- 
low each other immediately without intermission, or they 
may succeed each other with more or less regularity and with 
a distinct interval of insanity between them. These features, 
and others manifested in the disease, will be more strikingly 
shown by the detail of the particulars of a few cases than by 
description. 

The case which, as Baillarger * says, was most in his mind 
when he wrote his account of the disease under notice, is the 
first given by him in his original memoir, 2 on the subject to 
which reference has already been made. It is manifestly 
proper to reproduce it here : 

u Mademoiselle X., aged about twenty-eight years, has 
had since her sixteenth or eighteenth year several accessions 
of mania. After having been in good health for three years, 
there was a return, and since then the disease has never been 
absent. It appears in paroxysms, each one lasting about a 
month. 

"During the first fifteen days there are present all the 
symptoms of a profound melancholia ; then, suddenly, mania 
supervenes and lasts a like period. 

" When the period of depression begins, Mademoiselle X. 
finds herself overwhelmed with a sadness which she cannot 
subdue. A kind of torpor, little by little, takes possession of 
her mind and body. 

" The countenance assumes an expression of suffering, the 
voice is weak, the movements of the body are performed with 
extreme slowness ; very soon the symptoms become more de- 
cided, the patient remains seated, motionless, and silent ; the 
least excitation of any kind is painful to her ; sunlight 

1 u De la folie a double forme, 1 ' Annates medico-psychologiques, juillet, 1880, 
p. 5. 

3 Bulletin de Vacademie imperiale de medecine, t xix, 1853-'54, p. 341. 



CIRCULAR INSANITY. 569 

fatigues and hurts her eyes. Mademoiselle X. understands 
very well all that is going on around her. She comprehends 
the questions which are addressed to her, but she answers 
very slowly in monosyllables, and in so low a voice that 
one understands her with difficulty. At the same time, in 
conjunction with these symptoms, there are insomnia, want of 
appetite, and obstinate constipation ; the pulse is small and 
slow. 

"At the end of three or four days the countenance has 
become profoundly affected ; the eyes are surrounded with 
dark rings, are deep-set and without expression ; the com- 
plexion is pale or yellowish. 

"When this state has lasted fifteen days it ceases sud- 
denly in the night, and the general torpor is replaced by a 
period of high excitement. 

In the morning, the patient is found with her face ani- 
mated, her expression bright, her speech quick, her move- 
ments sudden and quick. She cannot remain an instant in 
the same place, and runs here and there as if impelled by an 
irresistible force. 

"Although her intelligence was weak, she is now bright 
and vivacious. She seizes with remarkable skill all the points 
in those around her which she can turn into ridicule. Her an- 
imation is inextinguishable, and is marked by continual epi- 
grams on the persons and things about her. In this new state 
the wakefulness continues, but the appetite has returned. 

" After fifteen days, calmness is reestablished. She recol- 
lects all that has happened during this second period. She 
is a little sad and composed, but very soon she resumes her 
ordinary condition. 

"The intermission is, unhappily, of but short duration ; 
rarely does it extend to two or three months ; generally, after 
fifteen or twenty days, another accession supervenes. 

"The patient, who, during the period of depression, took 
but little food, emaciated very rapidly. At one time she lost 
twelve pounds in fifteen days. During the period of excite- 
ment, and during the intermission, the appetite was very 
great, and the return to stoutness took place rapidly." 

As an instance of circular insanity, in which an interval 
occurs between the period of depression and that of excita- 
tion, I cite the following case from Baillarger : 3 

1 Op. el loc. cit, p. 345. 



570 DESCRIPTION AND TREATMENT OF INSANITY. 

" Mademoiselle M., aged twenty-four years, had her mother 
and grandmother insane. She has herself been melancholic 
for four years. At the beginning there were sadness, idle- 
ness, and ideas of suicide. These symptoms, which were first 
noticed in the month of May, gradually became more marked, 
and the patient grew entirely stupid. She passed the whole 
day in her chair, motionless and silent. Her eyes were wide 
open, and her expression was that of stupor. The complex- 
ion was pale, the extremities cold, the appetite almost abol- 
ished, and the urine flowed involuntarily. This condition did 
not begin to improve till the month of October. The prog- 
ress toward recovery was slow, and it was not till six weeks 
had elapsed that she was convalescent. Fifteen days had 
hardly elapsed when the symptoms of excitation appeared, 
and in a short time they were at their height. She made in- 
decent propositions to those around her, and sometimes com- 
mitted acts of violence. The period lasted about as long as 
the preceding one of stupor. 

" Since then she has had three similar paroxysms." 

There is no uniformity relative to the evolution of circular 
insanity. Sometimes the period of excitation follows at once 
that of depression, there being no intermission between them, 
and the transition taking place often in the night. Again, the 
symptoms of melancholia disappear gradually, and those of 
excitation supervene in the same way, so that the one step 
glides almost imperceptibly into the other. And again there 
is a distinct intermission of longer or shorter duration between 
the two periods. It is sometimes the case that the paroxysms 
follow each other without interruption, there being no inter- 
missions at any time, but depression and excitation coming 
one on the other in an endless round. On the other hand, the 
intermissions between the paroxysms may extend to a year 
or longer. 

It is also to be noted that there are all gradations in the 
intensity of the paroxysms, both as regards the periods of de- 
pression and excitation, from profound melancholia with stu- 
por and intensely acute mania to simple depression of spir- 
its and a little more than ordinary gayety. Geoffroy l gives 
the following case, the details of which were given to him by 
Baillarger, in which the phenomena were scarcely marked 
enough to be regarded as passing beyond the bounds of ec- 

1 These de Paris, 1861, p. 96, cited by Ritti, op. cit. y p. 196. 



CIRCULAR INSANITY. 571 

centricity, but in which, nevertheless, they were very charac- 
teristic : 

"There is a member of the Institute who, notwithstanding 
afolie d double forme with which he is affected, continues to 
take part in the meetings. To an attentive observer, how- 
ever, he is a different man according as he is in the period of 
depression or that of excitation. When in the first-named 
state, he enters the room without saying a word to his col- 
leagues, goes to his place, appears sad and cast down, indif- 
ferent to all that is said, and never speaking. When, on the 
contrary, he is in the stage of excitation, every one notices 
his entrance ; he talks to all, goes from place to place, speaks 
at each instant, constantly makes objections. After he has 
reached his home, his activity continues. He writes continu- 
ously, and dictates numerous memoirs to two or three secre- 
taries whom he has under his orders." 

The following cases, which occurred within my own expe- 
rience, are sufficiently interesting to deserve citation : 

H. S., a man twenty-seven years old, with hereditary ten- 
dency to insanity (his mother and two maternal aunts had been 
insane), consulted me, August 21, 1867. He informed me that 
he was subject to periodical attacks of melancholy, which 
were followed by paroxysms of great excitement, and that in 
the intervals, through one of which he was then passing, he 
was perfectly sane, and able to attend to his ordinary busi- 
ness, that of an importer of toys and fancy goods. 

About seven years previously, as his wife informed me, 
he had met with considerable business reverses, and had in 
consequence become very much depressed in spirits, having 
suicidal tendencies, but no actual illusions, hallucinations, or 
delusions. This condition lasted about six months, and then 
suddenly disappeared, being succeeded almost immediately by 
a state of exhilaration that was noticed by all with whom he 
came in contact, and who had known his former state. By 
many the change was supposed to be due to the excessive use 
of alcoholic liquors. He himself ascribed it to a quack medi- 
cine which he had been taking for some time. The difference 
was so great that, although it was not supposed that he was 
insane, it was, nevertheless, very evident to his partners that 
he was in no better condition to transact business than he 
had been during his state of depression. When suffering 
from melancholia he took no interest in his affairs, but left 



572 DESCRIPTION" AND TREATMENT OF INSANITY. 

everything to his partners to manage. It was impossible to 
ronse him sufficiently to get him to look into matters, and, 
when his advice was asked, he either gave the first reason 
that occurred to him, or declined to express an opinion. Now, 
however, everything was altered. He was meddling in all 
departments of the business, suggesting this thing and the 
other, making extensive purchases without consultation with 
the partners, and selling things at less than cost. He even 
rented an adjoining building, so as to be ready for an exten- 
sion of the business, which he proposed to make in a short 
time. 

At home there was fully as great a change noticed. For- 
merly, he had shown no disposition to converse, he took no in- 
terest in the household affairs, and, when a baby was born to 
him, refused to go to his wife's room to look at it. When it 
was brought to him, he said, u Take it away, I have seen as 
many of those things as I care to see," and immediately re- 
lapsed into silence. He did not see his wife till she was able 
to leave her room. His whole day was spent in sitting in a 
large arm-chair, with a book, from which he never read a line, 
in his hands. His appetite was bad, his bowels constipated, 
and he lost weight, his wife thought, to the extent of at least 
fifty pounds. He had in health weighed about two hundred 
and ten pounds. 

Although he never attempted suicide, he several times re- 
marked to his wife that he would like to die, and asked her 
what she thought would be the quickest and pleasantest mode 
of death. One day he remarked that, if the river were not so 
far off, he would go there and drown himself. 

But suddenly all this disappeared, and the most extraor- 
dinary change in his mental and physical condition super- 
vened. He talked incessantly, went to some place of amuse- 
ment every night, proposed all sorts of schemes for the fu- 
ture, wanted to sell the house he lived in, and build a larger 
and finer one, talked of buying a country-seat, purchased 
a large quantity of jewelry for his wife, and bought stacks 
of new clothes for her, himself, and the children. Some of 
his purchases were of an incongruous character, but many 
were unnecessary, and some that he spoke of were beyond 
his means. 

Daring this stage his appetite was enormous, and he rap- 
idly regained his lost weight. Sleep was bad. Sometimes 



CIRCULAR INSANITY. 573 

he would get up in the night and go out to take a " walk 
around the block," so as to be able to sleep better. He com- 
plained at times of a f illness of the head and of a pain in the 
forehead, but did not appear to attach much importance to 
these symptoms. Although fond of reading, he had never 
shown any literary ability ; but now he insisted that he was 
going to retire from business and devote himself to author- 
ship, especially to the writing of novels. He purchased sev- 
eral reams of paper, a desk, a gross of pens, and numerous 
books of reference. 

About this time, however, another change took place. He 
lost his excited manner, began to sleep well, ceased to speak 
of his many schemes, and became as sane in mind and as 
healthy and natural in body as he ever had been. The al- 
teration was gradual, but was fully effected in a week or ten 
days. He spoke of his past conduct, both in his period of 
depression and of exaltation, with regret. He seemed to have 
a distinct recollection of all that had occurred, and of the 
thoughts he had had, and expressed his decided conviction 
that he had been insane. 

He remained in perfect health, so far as could be observed, 
till February, 1862, when, without assignable cause, he sud- 
denly became melancholic, and in almost precisely the same 
way as before. This state continued till the 11th of March of 
the same year, when it ceased — not at night in his sleep, but 
while he was sitting in his library, with the unread book in 
his hand. He had been in that position since early morning, 
when suddenly he threw the book on the floor, jumped to 
his feet, and exclaiming "By Heaven, there's been enough of 
this ! " rushed out of the house, his wife and other members 
of the family after him, screaming for help, under the appre- 
hension that he was going to the river to drown himself. He 
was stopped by several persons, and brought back to his 
house, he laughing at the disturbance that had been created, 
and saying that he was the last man in the world to kill him- 
self, as no one could be happier than he. The state of excite- 
ment, of which this was the beginning, was as nearly as pos- 
sible like the preceding one of nearly two years before. He 
talked as he did then, bought clothes and jewelry, wanted to 
extend his business, and so on. It lasted till the 15th of April, 
when it disappeared in the night, while he was asleep, and he 
awoke perfectly sane. 



574 DESCRIPTION AND TREATMENT OF INSANITY. 

He remained well till the 9th of the following September, 
when he was again attacked with melancholia. This lasted 
till the 12th of October, when he dropped his book as before 
with a like exclamation, and wonld have rushed out of the 
house, had he not been held by two friends who were pres- 
ent. This stage continued till the 14th of November, when 
it disappeared in the night. 

Since that time, up to the period of his visit to me, he had 
paroxysms, of which the stage of depression and that of ex- 
citement were each of about a month's duration, with an inter- 
mission of about six months. All the periods of depression 
and all of exaltation had been as nearly as possible like oth- 
ers of their respective categories. 

At the time of his visit I could detect no evidence of men- 
tal derangement, but he and his wife informed me that the 
stage of depression was expected in a few days, and might 
appear at any moment. In fact, it came the next day, and I 
saw him when it was at its height. It was, in all respects, 
similar to the previous seizures, and which have been suffi- 
ciently described. 

This was on the 22d of August, 1867. On the 20th of Sep- 
tember he suddenly exclaimed, "This has got to stop," and 
started at the top of his speed to get out of the house. He 
escaped, notwithstanding the efforts of people in the street 
to stop him — for he was in his shirt- sleeves and slippers, and 
without a hat, and all supposed something was wrong — and 
ran about half a mile ; he then walked back, and the stage of 
excitement such as has been described was initiated. It con- 
tinued till the 24th of October, when it disappeared in the 
night. Since then he has continued to have the attacks, 
though they are not so long or severe as formerly, and the 
intervals are now over eight months. 

During the period that he has been under my care, he has 
had very little physical pain in any part of his body. I have 
seen him over twenty times in each stage of the paroxysm, 
and have always found ophthalmoscopic evidence of cerebral 
ansemia during the period of depression, and of congestion 
during that of excitement. He is now in Europe. 

In another case, the patient, a lady, aged thirty-six, mar- 
ried, with two children, and in good circumstances, having a 
slight hereditary tendency to insanity — a paternal uncle hav- 
ing died insane — became affected about the first of July, 1871, 



CIRCULAR INSANITY. 575 

with melancholia, with delirium of a mild form. The attack 
lasted till August 18th, when it suddenly disappeared. She 
remained well till November 24th, when she had a sudden 
accession of acute mania, during which she fought and struck 
at those who approached her, sang, danced, swore, prayed, 
uttered the most obscene language, preached a sermon, made 
efforts at masturbation, and otherwise so conducted herself 
that she was sent to an asylum. She remained there till the 
first of -March, when she was discharged as cured, though she 
had been free from delusion since the middle of January. 

In July, 1872, she had another paroxysm of melancholia, 
with delirium much worse than the previous one, as she made 
several determined attempts at suicide. She was sent back 
to the asylum and was kept there till October 26th, though 
she had been sane since the latter part of August. A month 
after her discharge she had a second seizure of mania, and 
then, December 2, 1872, I saw her for the first time. She was 
then in a state of the greatest excitement, but, unlike the 
previous attacks, there was no disposition to violence. She 
had illusions and hallucinations, mostly of an erotic character ; 
was very loquacious, sang at the top of her voice, talked ob- 
scenely, and sang obscene songs ; was very desirous of tak- 
ing off her clothes and showing her fine figure, etc. ; made 
repeated attempts at masturbation, but when stopped said, 
" All right, if you think it's wrong I won't do it," and burst 
into a hearty laugh. 

The ophthalmoscopic appearances were always those of 
cerebral anaemia during the stage of depression, and of hyper- 
emia during that of excitement. 

Under treatment this stage was kept within a condition of 
quietude when compared with the last seizure, and its dura- 
tion was shortened to less than a month, for on the 28th of 
December she awoke apparently perfectly sane. She con- 
tinued in good health, under treatment, till the 10th of 
March, a longer interval between the periods of depression 
and excitement than she had yet had. Then she experienced 
a return of the stage of melancholia with delirium, though in 
a much milder form. Under treatment the duration of this 
stage was shortened to two weeks, when she suddenly became 
sane, and has remained so ever since. 

In this case there was an interval between the two periods 
which go to make up a whole paroxysm, in which there was 



576 DESCRIPTION AND TREATMENT OF INSANITY. 

neither depression nor excitement. Moreover, the accession 
of the stage of exaltation was of a more violent character 
than is generally met with in the affection. 

In the description of the disease as given by Falret, 1 there 
is a gradual subsidence of one period and a gradual advance 
of the other ; then, again, a gradual disappearance until lu- 
cidity is reached. This period of remission is followed by the 
stage of excitement, for instance, and that by depression as 
before, and so on in an endless round for many years, or dur- 
ing the whole lifetime of the patient. It is to this form that 
Falret applies the term folie circulaire, while Baillarger em- 
ploys that of folie d double forme to the type described by 
him. It is, however, preferable to embrace not only these, 
but all other forms, under one designation. There is certainly 
no good reason for regarding them as any more than varieties 
of one affection. 

Falret considers the disease to be much more common with 
women than with, men. Of seven well-marked cases that have 
come under my observation, five were in women. It is a dis- 
ease of adult life, and is almost invariably developed in those 
in whom there exists a hereditary tendency to insanity. 

It may terminate in recovery, in secondary dementia, in 
transformation into some other form of insanity, or in death. 

e— KATATONIA. 

By katatonia is to be understood a form of insanity first 
described by Kahlbaum 3 and characterized by alternate peri- 
ods, supervening with more or less regularity, of acute mania, 
melancholia, and epileptoid and cataleptoid states, with delu- 
sions of an exalted character and a tendency to dramatism. 
The derivation of the word {fcararovos, stretcliing down) is 
taken by Kahlbaum to express the depressed mental and 
physical tension which is characteristic of the disease. From 
his monograph, and from that of Dr. J. Gr. Kiernan, 9 of Chi- 
cago, the only writer in the English language on the affection, 
I shall mainly take the description I am about to give. 

1 "Memoire sur la folie circulaire," Bulletin de Tacaderaie imperiale de 
medecine, t. xix, 1853-'54, p. 382. 

2 "Klinische Abhandlungen liber psychische Krankheiten," i. Heft, "Die 
Katatonie," Berlin, 1874. 

3 "Katatonia," The Alienist and Neurologist, October, 1882, p. 558. This 
paper was originally read before the New York Neurological Society, May, 1877, 
and was published in the American Journal of Insanity for July, 1877. 



KATATONIA. 577 

Katatonia may, like other varieties of insanity, be preceded 
by prodromatic symptoms similar in character to those which 
have been described in other parts of this work. There are 
pains or other abnormal sensations in the head, vertigo, in- 
somnia, irritability of temper. Again, it may begin with an 
epileptiform convulsion, or the condition of melancholia or 
exaltation may be the first noticeable symptom. Then the 
cycle begins : Cataleptoid phenomena accompany or follow the 
melancholia, which is generally of the form described in this 
work as melancholia with stupor, and a period of excitement 
supervenes, during which the patient has sensorial derange- 
ments in the way of illusions and hallucinations as well as 
delusions. Again, the melancholia appears, perhaps, in a 
modified form, with cataleptoid and waxy conditions of the 
muscles, and a disposition to talk in an exalted or dramatic 
manner. At times, during the course of the affection, there 
may be convulsions or involuntary muscular actions, such as 
roiling on the floor or bending of the body. Masturbation 
is a common accompaniment, and during the stage of excite- 
ment acts of violence may be committed. 

I cite the following case from Kiernan's memoir : 
U T. R., aged thirty-six, policeman, single, common-school 
education, intemperate, as were also his parents. The patient 
had been a masturbator, and had indulged in sexual excess. 
He was at first melancholic, subsequently maniacal, but, re- 
covering therefrom, became what his fellow-policeman called 
'stuck up.' His temper changed from good-humor to irasci- 
bility, and asylum treatment was at length rendered neces- 
sary. He was admitted to the New York City Asylum for 
the Insane, March 17, 1873. A week previous he had gone to 
church, but soon returned, saying he had been followed by 
droves of dogs. He was a tall, powerful, good-looking man, 
and, though he had asserted that he would not commit sui- 
cide, he had cut off the tip of his ear in an attempt of this 
kind. He was somewhat subdued in manner, and had hallu- 
cinations of sight and hearing. The day previous to admis- 
sion he was affected with spasm of the muscles of the ex- 
tremities. Four days after admission he manifested the 
delusion that he had committed a great crime, and refused 
food, but said, 'This is not a penance for the crime.' He re- 
quired artificial feeding for three days, took food voluntarily 
on the fourth, and again refused it on the fifth day. A period 
si 



578 DESCRIPTION AND TREATMENT OF INSANITY. 

of excitement then occurred, and he became a subject of hal- 
lucinations differing from those he had on admission. After 
treatment a short time with opium and hyoscyamus, he grew 
quiet and took food voluntarily but very suspiciously. In 
about a week after, a spasm of the muscles of the neck, fol- 
lowed by slight unconsciousness and slumber, occurred, the 
pupils dilating widely, and so remaining for a few days. Two 
weeks after, he had very sluggish movements of the lower 
extremities, bearing a very suspicious resemblance to func- 
tional paraplegia, but this was really an incomplete catalep- 
toid condition, involving also the muscles of the neck and 
upper extremities. The patient opened his mouth, and per- 
formed other simple actions of that nature ; these, however, 
were not ideational, but sensori-motor acts, as his attention to 
the subject was nil, and he was in a peculiar emotional state. 
That all the mental faculties were not in abeyance was shown 
by the fact that he involuntarily raised his hands, in an atti- 
tude of supplication, or as an acknowledgment of a favor 
just received. His pupils responded to light, and the or- 
ganic functions were performed as usual. This condition con- 
tinued for three days, with very little change, except that, 
when asked to perforin a simple action, the request would 
be obeyed, and the action continued indefinitely in an auto- 
matic way. 

" Five days after the beginning of the condition just men- 
tioned, the patient had a rapid, feeble pulse, the beats of which 
ran into each other, and did not correspond with the heart's 
action, which, though rapid, was otherwise normal. His eye- 
lids and lower extremities soon became cedematous, and the 
cataleptoid condition disappeared. The heart's action grew 
more irregular, the first sound being alone audible, and ac- 
companied with a loud, blowing murmur, heard at the base. 
Pulse one hundred and thirty-two, and more rapid in the 
neck than at the wrist ; respirations were increased, the lungs 
and temperature being normal. The heart's action soon re- 
turned to its normal condition, and the murmur disappeared. 
The treatment was directed to the alimentary canal only. 
The patient then became entirely unconscious as to his sur- 
roundings, though taking food and performing other actions 
involving only the organic functions normally, and so con- 
tinued for about a week. He then began to have tonic con- 
tractions of the muscular system, followed by lessening of the 



KATATONIA. 579 

oedema, which, finally disappeared. The cataleptoid condi- 
tion then returned, and was accompanied with considerable 
waxy mobility. Two days after, his muscles were extremely 
rigid, and he remained apparently unconscious for some time. 
One morning he suddenly spoke, and being asked his reason 
for not speaking before said, ' They told me not to,' and, when 
asked who told him not to, replied, ■ God and the others, 'and 
began to weep. 

u The following day he had a return of the cataleptoid 
condition, in which he remained for some time. These alter- 
nations continued for three months, when he became sud- 
denly violent, tore off a bar from the window, and tried to 
make his escape. This excitement continued three days, the 
patient then passing again into the cataleptoid condition, on 
emerging from which he was markedly dignified and very 
formal in conversation. This manner of speaking and act- 
ing continued for three months. He then had another cata- 
leptoid relapse, succeeded by an attack of melancholia at- 
tonita (melancholia with stupor). Then followed a condition 
during which his pupils at first contracted and then dilated, 
his left hand contracted firmly, and from it a quivering mo- 
tion extended over the left side, and gradually involved the 
entire body. The irregularities of circulation formerly ob- 
served once more .appeared, and, as before, went away with- 
out special treatment. 

" Melancholia atonita became the predominant condition, 
accompanied, however, by increased susceptibility to external 
influences. This remained four months, and was followed by 
a cataleptoid condition, with much waxy mobility. While in 
this state he was found to be developing phthisis. The dis- 
ease ran a rapid, somewhat irregular course, terminating life, 
July 22, 1875, twenty-six months after his admission into the 
institution." 

This is a fairly typical case of katatonia. Four others are 
reported in detail by Dr. Kiernan, though he states that 
forty -six cases were observed by him. 

Before giving the particulars of the four cases that have 
come under my own observation, I desire to cite a well- 
marked instance which, though reported by its distinguished 
author as a case of circular insanity, ovfolie d double forme, 
is undoubtedly to be considered one of katatonia. No one, I 
think, reading the graphic description given by Dr. Kraft- 



580 DESCRIPTION AND TREATMENT OF INSANITY. 

Ebing, l could fail to place the case in its proper nosological 
position, as an instance of the affection under consideration. 

The patient was a man, twenty- two years old. His father, 
shortly before his death, had some kind of psychical troubles, 
and his mother suffered from habitual headaches. The pa- 
tient was well, up to the period of puberty. At this time he 
got into bad health, suffering from general debility and pal- 
pitations, and on these accounts was excused from military 
service. This state was doubtless due to onanism, which the 
patient had long practiced to a great extent. In 1877, after 
a violent emotional disturbance, he passed suddenly into a 
state of stupor with intervals of maniacal excitement. Eight 
days afterward he was well. On the 28th of August, 1878, 
he became excited at a dance, drank to excess, and was sub- 
jected to mortifications by his mistress. On the 26th he ap- 
peared to be depressed and in bad humor. A few hours after- 
ward, he fell into a profound stupor, without movement. 

On the 28th he began to gesticulate, to speak by asso- 
nances, to discourse, and to be in continual motion. He upset 
everything, rolled on the floor, demanded that the curate 
should marry him, and talked in a manner altogether inco- 
herent. 

On the 30th he again became stupid, and was in this state 
when he arrived at the clinique. Aside from the fact that his 
pupils were dilated and not very active, nothing special was 
noted relative to his physical condition. He lay on the floor 
motionless, mute, and stupid. 

On the 31st another period of excitation began, and again 
he spoke by assonances. He recited, in good German, some 
passages from the Bible, preached, and made tragic gestures, 
saying with great pathos all kinds of inanities ; for example, 
" Twice six are twelve, eighteen is my brother," etc. When 
the attempt was made to undress him, he resisted with en- 
ergy, cried out in a loud voice, grit his teeth, and contorted 
his face. As soon as he was let alone, he raised himself, and 
with a menacing tone said, " Come here ! " For several hours 
he was quiet, and tolerably lucid up to the period of the visit. 
Sometimes also he had periods of stupor lasting several hours, 
during which there were theatrical poses and cataleptiform 
states, but in reality the patient remained until the 16th of 
September in a state of maniacal excitation, with insomnia, 
1 " Lehrbuch fur Psychiatric," Stuttgart, 1880, t. iii, p. 124. 



KATATONIA. 581 

great incoherence, recognition of what was going on abont 
him, volubility, during which he discoursed in good German 
of God, the Virgin, and his mistress. 

On the 16th of September, however, he fell again into a 
state of stupor, which continued till the 14th of November. 
During this condition he had no consciousness of his acts, 
passed his urine and faeces in the bed, assumed cataleptiform 
and other forced positions, and remained for a long time lying 
in one place, his eyes in a state of convergent strabismus, 
and fixed on vacancy. Generally he was mute, but when 
he talked he uttered all kinds of absurd expressions, and 
spoke by assonance, saying over and over again, "Flug, 
fliige, fleck," etc. By the 13th of November he was a little 
less stupid, said the blood was rushing to his head and gave 
him vertigo. In fact, there often was a redness of his face. 
It was observed that he masturbated during the stupor, and 
that the act increased the redness of his face. 

On the 14th of November the period of excitation reap- 
peared. He was wakeful, and again began in a pathetic man- 
ner to say things without sense, and spoke by assonances. 
There were great incoherence and a tendency to utter isolated 
words and phrases. He took those about him for the Pope 
and bishops, was in a state of continual agitation, rolled over 
and over in bed, and kept on uttering isolated words. Then, 
again, he assumed forced attitudes, and upon occasion showed 
anger. 

On the 29th of November he was quiet, and in a stupor. 
This was characterized by symptoms similar to those of the 
preceding corresponding states, and lasted only a few days. 
By the middle of December he was quiet, and on the 10th of 
January he was discharged cured. 

Certainly this was a typical case of katatonia. 

A merchant engaged in the importation of Vienna goods 
consulted me March 11, 1880, or rather I was consulted in re- 
gard to him by his brother and one of his partners in business, 
and the patient, very much against his will, was brought to 
my consulting-room. 

He entered the apartment with all the air of a prince, and 
sat down without deigning to address me. When I spoke to 
him he at first made no answer, but on my persistence with 
my questions of what his name was and where he lived, he 
looked at me for a moment in a supercilious way and finally 



5S2 DESCRIPTION AND TREATMENT OF INSANITY. 

said, "And the Lord spake unto Moses, saying." This he 
kept repeating, whether spoken to or not, during the whole of 
his visit, extending over an hour. Upon inquiry, I ascertained 
that without assignable cause he had, eight days previously, 
suddenly passed into a condition of melancholia with stupor, 
during which he was most of the time silent and in a state 
of almost complete immobility. It was also noticed that, 
when anybody took hold of his hand, the member remained 
for several minutes in the position in which it was left. On 
one occasion his neck had continued twisted, with his face 
as far as it could be turned over his left shoulder, for over half 
an hour, and had then slowly returned to its natural position. 
On my taking hold of his arm and extending it at right 
angles with his body, and leaving it there, it remained out- 
stretched for thirteen minutes, and then slowly descended to 
his side. All the time that I was making this and other ex- 
aminations of his muscular system, he was saying in a loud 
voice, " And the Lord spake unto Moses, saying." 

The pupils were equal, were largely dilated, and did not 
react well to light. 

I requested him to follow me into another room, in order 
that I might make an ophthalmoscopic examination. He took 
no notice of what I said to him, and, when his friend and I 
raised him from his chair to lead him into the apartment, he 
made himself as rigid as a bar of iron, so that we had to carry 
him. Arrived there, he would not sit down, but stood as erect 
as a statue. On feeling his muscles, it was easy to perceive 
that all were in a state of extreme tension. It was impossible, 
I found, to make the examination I desired ; so, after prescrib- 
ing the bromide of sodium for him, in doses of twenty grains 
three times a day, I sent him away, with instructions to return 
in five days, and to continue the medicine till then. 

On the 16th I saw him again. He was then in a state of 
high excitement. He entered the room without hesitation, 
and at once began an extemporary speech on the beauties of 
the solar system. Every sentence, however, he ended with 
the phrase, u And there shall be no night there." I wrote 
down from memory soon after his departure a portion of his 
address, as follows : 

" And now, my friends, what is this solar system of which 
we have heard so much % And there shall be no night there. 
Is it composed of homogeneous matter throughout its whole 



KATATONIA. 583 

extent, or are some parts of it different from others ? And 
there shall be no night there. Is it to be supposed that the 
sun, a light-giving orb, is of the same physical structure as 
the moon, a light-reflecting orb ? And there shall be no night 
there. Is the earth, a light-receiving orb, like the sun, a light- 
giving orb, and the moon a light- reflecting orb ? And there 
shall be no night there ' ' — and* so on for half an hour. 

Since his last visit he had had several spasmodic seizures 
without loss of consciousness, coming on before the cessation 
of the period of melancholia, which took place on the 14th 
of March. Since that time he had done very little else than 
to declaim from Shakespeare and other poets, and deliver ex- 
temporaneous addresses. He was disposed to be very quar- 
relsome, and had knocked the hat off of a man's head on his 
way to my residence, because he thought the man had made 
a face at him as he passed. The convulsive seizures had con- 
sisted of movements of the head and of the muscles of the 
neck. The head, for half an hour or more, had on several 
occasions been kept in continued motion from side to side, 
while the face was undergoing contortions. One afternoon 
he had stood before an engraving of Washington and bowed 
for over an hour, and would have continued had he not been 
taken away by force. 

On my asking him how he felt, he answered, " It's a wise 
child that knows its own father, but I feel quite well, I thank 
you." On my asking how he had slept the previous night, 
he replied, "It's a wise child that knows its own father, but I 
slept very well, I thank you." When I asked if he had any 
pain in his head, he said, " It's a wise child that knows its 
own father, but I have no pain in my head, I thank you." 
And so on, to every question I put to him. 

Before he left, he began to speak in a staccato way : "I — 
think — I — shall — go — to — the — the — a — tre — to — night — to — 
see — Booth — in Ham — let. ' ' 

I asked him why he spoke in that manner. He replied : 

"Be — cause — I choose — to do — as — I choose to — do — and 
that — is — why — I speak — as — I — choose — to — speak. ' ' 

" But," I said, " it is a silly way of talking." 

" I — came — to you — for — med — i — cal — advice — and — not 
— for — a — les — son — in — el — o — cu — tion. ' ' 

At this time there were the ophthalmoscopic appearances 
of cerebral congestion. The pupils were normal. 



5S± DESCRIPTION AND TREATMENT OF INSANITY. 

So far as I could ascertain, there had been no illusions or 
hallucinations, but there were delusions that he was to be 
made the director of the opera and manager of all the thea- 
tres, with a large salary from the State. 

I directed the continuance of the bromide of sodium. On 
the 22d I saw him again. There was then a condition of cat- 
alepsy, without marked melancholia. Though indisposed 
to talk, he would answer if the question were repeated. The 
arms, legs, and head were in a waxy state, and at times he 
would take dramatic attitudes and keep them for several 
minutes. He stood in my consulting-room for seven minutes 
as ' ' A jax defying the lightning, " and for the like time as the 
" Apollo Belvedere." " The dying Gladiator" he could only 
maintain for a few minutes. 

At the time there was no mental aberration of any kind, 
but there was a slight degree of exhilaration present which 
was not natural to him, and a slight disposition toward 
dramatism. This, however, did not extend to speech, but 
only to the attitudes which he would assume without prompt- 
ing. 

Under the continued use of the bromide, this state passed 
away in a few days, and there were no further manifestations 
of the disorder. 

The next case that came to my notice was that of a young 
German, living in St. Mark's Place in this city, whom I saw 
in consultation with Dr. Garrish. In this instance, the cata- 
leptoid state and the tendency to utter high-flown language, 
and to assume histrionic attitudes, were strikingly exhibited. 
At the period of my examination the mental condition was 
that of excitement. The patient was talking volubly nearly 
all the time, walking the floor, gesticulating, grimacing, and 
occasionally speaking in alliterative verse. He had hallucina- 
tions of hearing, and would often stop and listen for an in- 
stant with a rapt expression of countenance. Then he would 
exclaim in pompous tones, "My lord, it shall be done!" 
This he repeated many times. He had passed through a stage 
of melancholy before I saw him. This had lasted a week 
or more, and during its continuance the patient mostly sat 
motionless in a chair, mute to all questions, and never taking 
the initiative in talking. Frequently, however, when spoken 
to, though he would not answer, tears would flow in pro- 
fusion, and he would groan aloud. He afterward said that 



KATATONIA. §85 

lie had not spoken, becanse lie had the idea that it had been 
decreed that, if he nttered a single word, his mother would 
at once die. I did not see this patient again, bnt was in- 
formed that he recovered under the bromide treatment ad- 
vised. The pupils were contracted, and the optic disk and 
fundus of the eye congested. 

The third case was that of a physician from a Southern 
city, who was brought to me by his friends, August 31, 1882. 
He was then in the stage of melancholia with stupor, attended 
with cataleptoid symptoms. He would not speak, but sat as 
long as allowed, motionless, with his eyes cast on the ground. 
If physical efforts were made to move him, his whole muscu- 
lar system was thrown into a state of extreme tension. If the 
attempt were made to raise his arm from his side, for in- 
stance, the limb became rigid, and it was almost impossible 
to move it ; at the same time there was no sign of any volun- 
tary effort at resistance on his part. He sat as composedly 
as before on his chair, without a change of countenance, 
though the muscular strength brought to bear by him was 
certainly very great. 

When I requested him to walk into an adjoining room, in 
order that I might make an ophthalmoscopic examination, he 
sat without moving a muscle. It was necessary to carry him, 
but, as soon as touched for that purpose, his body became 
perfectly rigid, and he could not even be made to sit down. 
He stood as erect as a statue. He appeared to be in a condi- 
tion not unlike that of a person suffering from tetanus, in 
whom the slightest impression made upon the skin is suffi- 
cient to induce a spasm. 

Previous to my seeing this patient, he had had repeated 
paroxysms of excitement, alternating with periods of melan- 
cholia, with stupor and cataleptoid phenomena. 

After leaving New York, he improved to some extent, and 
would have improved still more, could he have been induced 
to take the mixture of bromide of sodium and fluid extract 
of ergot prescribed for him. 

The only other case of katatonia that has come under my 
observation is that of a Swede, a man of about thirty years 
of age, who came to my clinique at the New York Post-Grad- 
uate Medical School February 15, 1883, and who formed the 
subject of a clinical lecture delivered to the class of medical 
practitioners in attendance. Twelve years previously, the 



586 DESCRIPTION AND TREATMENT OF INSANITY. 

man, while working in a stone-quarry, had a piece of timber 
fall upon his head. He was stunned for a few minutes, but 
the blow was not a serious one, and he recovered ; subsequent- 
ly, however, he had some head-trouble, and did not speak for 
several weeks. All morbid symptoms disappeared, and he 
remained well till about twenty days before I saw him, when 
he became excited, thought people were going to kill him, that 
he had committed some crime, etc. This state only lasted 
a few days, when it was succeeded by a period of melancholy 
with stupor, during which he was mute, and sat nearly all 
day in one position. If his baby were put into his arms, he 
would hold it for hours without moving his hands or other- 
wise changing his position. He never asked for food or ap- 
peared to care about eating. If his meals were brought to 
him, cut up, and put to his lips, he would sometimes open his 
mouth and eat ; again, he would refuse. In my preliminary 
examination, I soon discovered the cataleptoid phenomena and 
the rigid state of his muscular system generally. Before the 
class, I stretched out one of his arms, and he kept it in a per- 
fectly horizontal position for over ten minutes, when his broth- 
er, fearing he might be injured, put it down. Again, on trying 
to raise his arm, it was held so strongly against his side that 
it was impossible to move it. No answers could be obtained 
from him. He sat bolt upright, staring at vacancy without 
the least expression, unless it were one of slight astonish- 
ment, on his face. This attack was supposed by his father 
to be due to grief caused by the death of one of his children 
about a month before. I prescribed the bromide of sodium 
in doses of thirty grains three times a day, and directed him 
to return in a week for further observation. On his return at 
the time fixed upon, the cataleptoid phenomena had entirely 
disappeared, but there was still a tendency to dramatism. 
He came again on the 1st of March, and was discharged 
cured. 

Many cases of unrecognized katatonia are to be found re- 
ported in writings on psychological medicine. One of the 
earliest is the following : ' 

James W. L., aged twenty-nine, was admitted into the 

hospital May 10, 1821. This young man had been a patient 

in the hospital before, and had remained for twelve months, 

when he was placed on the incurable list ; but, having got 

1 " Sketches in Bedlam," etc., London, 1823, p. 155. 



KATATONIA. 587 

much better, and continuing to improve for some time, six 
months' leave of absence was granted him, at the end of which 
time he came back completely well, and was discharged 
cured. 

The character and symptoms of this patient's disorder, it 
is stated, were extremely curious. When the paroxysm came 
on, however he happened to be situated, his whole form from 
head to foot became stiff, as if all his joints and muscles were 
ossified. His eyes, though staring open, became fixed, and 
he foamed at the mouth. If sitting or walking, when his fit 
came on, he would instantly fall to the ground, completely 
extended at full length on his back with the same symptoms 
of rigid stiffness and insensibility ; his eyes, open and in- 
clined upward, were insensible to the touch of a hand passed 
over them, which did not produce the slightest wink. No 
symptom of animation remained, with the exception of breath- 
ing, and this so faintly as to be scarcely perceptible. His 
condition, in all other respects, resembled death, and in this 
state he would sometimes continue for one, two, three, and 
even four days, without any apparent change. He could not 
be induced on these occasions to eat or take any kind of sus- 
tenance, except under the direction of medical gentlemen, 
when rich broths were administered by injection. During 
the fits his whole person was literally as stiff as a plank, and 
he might have been raised to a perpendicular position and 
carried from place to place like a ladder without the least 
appearance of flexibility. Toward the termination of these 
paroxysms, when a hand was passed over the eyeballs, they 
would sometimes move, which was a prognostic of his recov- 
ery. On being roused from his stupor, he recollected nothing 
of what had passed, but he would speak of dreams, visions, 
heaven, hell, and the strange things he had seen. After 
these fits he always appeared weak and dejected. 

Other cases of a similar character have been reported by 
Cullere, 1 Lagardelle, 2 and others, but without differentiating 
the affection now under notice, and without reference to Kahl- 
baum's monograph. The disease is more common in men 
than in women. Of twenty-six cases reported by Kahlbaum, 

1 " Observation de catalepsie chez un hypocondriaque persecute," Ann. 
med.-psy., mars, 1877, p. 177. 

2 " Catalepsie consecutive a une manie aigue," Ann. med.-psy., Janvier, 1878, 
p. 38. 



5SS DESCRIPTION AND TREATMENT OF INSANITY. 

twenty were in males. All of Kiernan's cases were in males, 
but this is explained by the fact that the asylum of which he 
was one of the medical officers had only male patients. All 
my cases were also in males. 

/—PRIMARY DEMENTIA. 

By primary dementia is to be understood a form of mental 
derangement characterized by the more or less complete weak- 
ness of the faculties of the mind, not secondary to any other 
form of insanity, but beginning as such in an individual pre- 
viously sane. 

The affection may be developed with great suddenness as 
the result of some moral shock, or it may supervene gradually. 
In the former case, the symptoms reach their highest degree 
of intensity with great rapidity ; in the latter, their progress is 
slower, and may be interrupted by periods of remission or 
intermission. 

In instances of gradual progress the first symptoms may 
be of a very indistinct character. The patient evinces less 
concern than formerly in passing events, or in thosa things in 
which he would naturally be supposed to be interested, such 
as his family, his business, his food, etc. Perhaps he shows 
this first and. most strikingly in regard to his dress and habits, 
for carelessness in the one and a disregard of the proprieties 
of life are among the earliest manifestations of primary de- 
mentia. Nevertheless, the changes from his normal charac- 
teristics are at first so very slight that they are not often at- 
tributed to their real cause, but are supposed to be due to 
mental preoccupation. 

But little by little these phenomena become more intense, 
and there is also observed a weakness of the emotions, which 
is manifested by the display of excessive joy or grief at the 
occurrence of what to persons of normal mind would be slight 
disturbing causes. Tears are therefore shed over the veriest 
trifles, and violent laughter will be indulged in at circum- 
stances which have little, if any, of the element of mirth 
about them. At times there may be an entire reversal of the 
ordinary evidences of feeling — the individual laughing when 
he would naturally cry, or at least feel sorrowful, and shedding 
profuse tears at some circumstance calculated to excite risi- 
bility in others. Thus, a young man, a patient of my own, 
laughed a whole morning over the intelligence that a railway 



PEIMARY DEMENTIA. 5S9 

accident had occurred by which a dozen or more persons were 
killed, one of them being his own mother ; and the next day 
cried like a child over an anecdote in the funny column of a 
newspaper. 

The ability to comprehend matters submitted to the un- 
derstanding is markedly impaired, and there is a difficulty in 
concentrating the attention sufficiently to get a correct idea of 
very simple subjects, while abstruse ones escape altogether. 
The faculty of observation, of directing the sensorial organs 
to the acquirement of information, is so greatly lessened that 
the most stirring events may occur in the presence of the 
subject of dementia, to which apparently his attention is fully 
directed, and yet, when asked immediately afterward in regard 
to them, he can scarcely state a single one of the details. The 
like failure is shown when he attempts to read aloud from a 
printed page : words are omitted or misplaced, without his 
being aware that mistakes are being committed. In writing, 
similar errors are perpetrated. 

The memory soon begins to show signs of weakness, and 
this is at .first mainly in regard to recent occurrences, though 
eventually even those of childhood are forgotten. A slight 
degree of amnesic aphasia is not infrequently developed, and 
the names of persons or things are forgotten. Many of my 
own patients have not been able to tell the cities in which 
they lived, or the names of their wives or children. As a 
rule, substantives are more readily forgotten than other 
words, and numbers, I think, are next in order. 

The memory of events, as the disease advances, becomes so 
bad, that circumstances which occurred only a few minutes 
previously are forgotten. I entered the room of a patient who 
had become the subject of primary dementia very suddenly, 
in consequence of receiving intelligence of great losses in busi- 
ness, and in whom the memory was so far abolished that he 
could not tell whether or not he had dined, though the knife 
and fork were in his hands when I opened the door. This 
patient did not know his wife's name or the name of any one 
of his children, or the number of his house, or whether his 
father and mother were living or not, though he had only 
been affected eight days. 

The will suffers with the other mental faculties, and often 
to a much greater extent. The patient is unable to rely on 
his own judgment, even in the simplest matters, or to arrive 



590 DESCRIPTION AND TREATMENT OF INSANITY. 

at a determination. Indeed, he does not make the attempt. 
If left entirely to himself, he would, in the extreme stage of 
the disease, do nothing whatever : if told to rise, he rises ; if 
to sit down, he sits down ; if to walk, he walks, and so on. He 
acts, as a matter of course, in accordance with the directions 
given him, provided they are commands which are to be 
obeyed at once. Otherwise, they are forgotten almost as soon 
as they are given. Probably no one symptom is more sug- 
gestive of the extreme condition of mental decay than the 
complete paralysis of the will, which so often exists in de- 
mentia. 

Incoherence is generally exhibited by all dements after 
the condition is well established. It would seem as though 
there were not sufficient mental force to follow an idea out to 
its legitimate expression in words, and, as there is a f orgetf ul- 
ness of words, the language used consists of imperfect expres- 
sions, both as regards quantity and quality. The incoherence 
of a patient suffering from primary dementia is shown in the 
following letter, which he was told to write me as a statement 
of his condition at the time : 

" You inform you I have in the health as you to you de- 
sired my head to-day yesterday is good and better as to you 
I hope. Sleep in my you to me good, and as before yesterday 
in the day and did walk to you as to you directed, my no 
more to-morrow and can more express. When see in next 
week my health still." 

By this he intended to say about as follows : 

"As you directed, I write to inform you of my health. 
To-day my head aches, but yesterday it was well, and I hope 
will be better. I sleep well, better than I did before. As you 
directed, I took a walk yesterday. My medicine will be all 
gone by to-morrow, but I can get more by express. I hope, 
when I see you next week, that my health will be still better." 

Some of the subjects of dementia are affected with illu- 
sions, hallucinations, and delusions, but these are generally 
of a mild or puerile form, and are variable in character. The 
delirium which sometimes exists is of a low type, and the 
speech is not only incoherent, but is expressed in indistinct 
mutterings. Occasionally, however, there is a more exalted 
delirium present, and then acts of violence may be com- 
mitted. These would, perhaps, be more frequent, but for the 
deficient intelligence and physical strength of the patient. 



PRIMARY DEMENTIA. 591 

Destructive tendencies are more frequently manifested, and 
often appear to be of an automatic character. Buildings may 
be set on fire, articles of value destroyed, and animals killed 
or injured, from mere wantonness or deficiency of mind, just 
as similar acts are perpetrated by children. From like in- 
fluences, homicides may be committed. In such cases the 
knowledge of right and wrong is lost, and in extreme cases 
the natural instincts appear to be abolished. Demented moth- 
ers kill their own children. Suicides of an intentional char- 
acter are never committed by the demented, though self-de- 
struction through ignorance is not uncommon. 

A curious tendency in some dements is to the repetition 
of some act or phrase, and this indefinitely. Often, for many 
years, one patient will always turn round three or four times 
before sitting down, another makes profound salaams during 
certain periods of the day, another before speaking performs 
certain movements with his fingers, and so on. Again, some 
sentence is caught up and repeated thousands of times. A pa- 
tient of mine, whenever spoken to, always first said, "Bosco- 
bel, boscobello, boscobellito, boscobellitito, boscobellititotito," 
before answering. It has appeared to me that, in some cases 
at least, there has been an idea that the acts or words were 
employed as a charm to assure good luck, but that, in the 
decay of the mind, the reason has been forgotten, while the 
movement or language has been continued automatically. I 
have observed dements who, in the beginning, could allege a 
motive for the performances in question, but who, at later 
stages of their disease, had lost all recollection of the original 
incentive, while persisting with the manoeuvres or peculiar 
expressions. 

A prominent feature in dementia is the loss of the sense 
of decency in patients who are its subjects. Obscene words 
are used to express their wants or appetites, and acts are per- 
formed in the presence of others for the doing of which even 
the most vulgar in a state of sanity seek seclusion. An edu- 
cated and refined man or woman will, for instance, urinate in 
the public drawing-room of a hotel without apparently being 
aware that anything at all unusual is being done ; and others, 
again, will make persistent public attempts at masturbation 
or sexual intercourse — not with the fury of the acute maniac, 
but automatically, and as if properly satisfying a natural ap- 
petite. 



592 DESCRIPTION AND TREATMENT OF INSANITY. 

C opiophagy, or the eating of excrement, thongh not con- 
fined to the subjects of dementia, is more frequent with them 
than with other lunatics. 

While the acute maniac and the melancholiac eat their 
excrements from illusions and delusions, the subjects of de- 
mentia-are actuated by no particular motive other than such 
as would arise in the mind of an infant. Very young children 
put everything, even their excrement, into their mouths, im- 
pelled by what is with them the most powerful of all their 
instincts, if not the only one — the taking of food. Some de- 
ments act in the same way, and eat not only their own excre- 
ment, but that of others, and even of the lower animals. I 
have seen the subject of primary dementia playing with her 
excrement as a child would play with mud, and a few weeks 
subsequently, when the disease had advanced to a further 
point, eating it as a child would eat molasses. In the case of 
a patient, a lady, who became the subject of primary demen- 
tia from emotional causes, there appeared to be an active 
appetite for fecal matters. Not only would she, whenever 
the opportunity occurred, eat her own excrement, but she 
devoured with avidity that of an infant to which, occasion- 
ally, she could get access. 

The subjects of dementia constitute the greater number of 
those patients in lunatic asylums to whom the term ' ' wet 
and dirty" is sometimes applied. They obtain the name 
for the reason that they are in the habit of passing their 
urine and faeces in their clothes or in bed, and hence are 
almost always in the condition expressed by the words. To 
a great extent this tendency is under the control of the at- 
tendants, and is scarcely ever met with in well-regulated 
asylums. 

The course of primary dementia, both as regards intensity 
and duration, is subject to great variation. Some cases reach 
their height in a few weeks or even days, while others advance 
so slowly that several years are required to arrive at the full 
development. In others, again, a certain stage is reached, 
and then further progress seems to be in a great measure 
arrested. But, whether slowly or rapidly, the course of pri- 
mary dementia is always toward a further degradation of the 
mind. After a time, when the mental faculties are wellnigh 
entirely abolished, and the individual is, as Dagonet remarks, 
nothing more than a stomach, life may be prolonged for a 



SECONDAKY DEMENTIA. 593 

long period. 1 In other cases, especially those which come on 
suddenly and advance rapidly, death generally takes place 
in a short time, and usually by exhaustion, or from the super- 
vention of some intercurrent disease. 

In the foregoing description of primary dementia I have 
attempted to present an account of the affection when it is 
fully established and is advancing with more or less rapidity 
toward complete development. But there are many grada- 
tions in the degree of intensity with which it appears. Some 
patients preserve for many years a tolerable amount of intel- 
ligence, and are able to extract considerable enjoyment from 
life, or to experience its pains. They do feel, even though 
they do not feel very acutely. In other cases some one or 
more of the mental faculties become impaired, while the 
others retain almost their original vigor. Thus, the memory 
may be the only part of the mind which suffers, or the emo- 
tions may be weak and easily affected, or the will alone shows 
any serious evidences of deterioration. But, although the 
affection may begin by involving a single category of faculties 
only, it is generally the case that the others, sooner or later, 
become involved. Physically the subjects of dementia are 
generally in good condition. The digestive powers are effec- 
tive, there is little or no wear and tear of the body through 
mental influence, they sleep well, and they usually get fat. 

g — SECONDAEY DEMENTIA. 

Secondary dementia is that variety of mental derangement 
in which there is a decay of the faculties of the mind as a 
consequence of some preexisting form of insanity. In most 
of its features it does not differ essentially from primary de- 
mentia, but, originating as it does, gradually, and from the 
partial conversion of another species of mental aberration, it 
retains more or less sharply the characteristics of the disease 
from which it has been derived. 

Thus, the subject of hypochondriacal melancholia, who 
has the delusion that a galvanic battery is in his stomach, 
continues to entertain the same erroneous belief through the 
whole course of the secondary dementia into which he may 
pass, so long as the mind is capable of believing anything ; 
the acute maniac settles down into some one or two of the 
delusions he has entertained, and holds them till the mental 

1 Op. cit., p. 358. 
38 



59tt DESCRIPTION AND TREATMENT OF INSANITY. 

vigor is so greatly impaired that the intellect can no longer 
be concentrated upon an idea, or even an idea be formed ; and 
the patient with circular insanity continues to exhibit in a 
degraded way the alternations of excitement and depression 
which characterized his disorder when it was, so to say, a 
robust affection. Illusions, hallucinations, and delusions may 
therefore exist throughout the greater part of the course of 
secondary dementia, as may also morbid impulses, fears, and 
tendencies. 

In other respects secondary dementia, as I have said, is 
similar to the primary form of the disease, and therefore re- 
quires no additional description. 

7l — SENILE DEMENTIA. 

Senile dementia is that form of insanity which occurs as 
the result of old age, and which is characterized by the decay 
of the mental faculties. Spontaneously it rarely makes its 
appearance before the sixtieth year, and generally not till 
after the sixty-fifth or seventieth. It may, however, as a 
consequence of wounds or injuries, or of some exhausting 
disease, ensue at even the fiftieth year. 

The first symptom noticed is almost always a weakness of 
the memory, and this is soon followed by other evidences of 
failing intelligence. The patient ceases to recognize persons 
whom he has known for many years, and even his own chil- 
dren are mistaken for other persons. He forgets where he 
lives, and can not even find his way from one room to another 
in his own house. Owing to this failure of the recollection, he 
repeats over and over again such anecdotes as his intellect 
enables him to comprehend, forgetting that he has told them 
probably not ten minutes before. 

It often happens that radical changes in the character and 
disposition are among the earliest phenomena. From having 
been liberal and generous in money matters, he becomes ava- 
ricious and penurious to an extreme degree, grudging every 
little item of household expense, and living, if left to himself, 
in a way scarcely befitting one of the lower animals. Occa- 
sionally there are periods of low delirium, marked by illu- 
sions and hallucinations, and by various morbid fears, or by 
delusions in regard to his personal safety. He is exacting in 
his demands, and readily imbibes ideas of neglect on the part 
of those about him, or of persecution or injury. At the same 



SENILE DEMENTIA. 595 

time lie begins to show signs of lack of carefulness and tidi- 
ness in regard to dress and personal habits, and finally reaches 
a stage in which propriety and decency are entirely disre- 
garded. 

The failure of the power of the attention is another one 
of the evidences of diminished mental strength, it being often 
impossible for the patient to concentrate his perceptions or his 
intellect upon any matter to which they may be directed. As 
in the other forms of dementia, the emotions, especially those 
of an entirely selfish character, are sometimes unduly exhib- 
ited in a weak and childish manner. The speech is very fre- 
quently incoherent from an early period, and is always so in 
the latter stages of the disease. 

The power of the will is generally greatly diminished, and 
sometimes utterly abolished, the patient relying altogether on 
those around him for guidance, or rather being perfectly pas- 
sive in their hands. At times, however, a spirit of unreason- 
able determination or obstinacy is developed, in regard usu- 
ally to some trifling matter, but again to a subject of great 
importance. I have known a patient in an early period of se- 
nile dementia when her ability to manage her affairs was still 
recognized, refuse to sign receipts for money paid her. She 
could allege no reason for this conduct, but simply declared 
that she would not sign them. On another occasion, she per- 
sistently refused to affix her signature to the deed of a piece 
of property she had sold a few days before. When asked if 
she desired to recall the sale, she said no, but that she would 
sign no papers ; they must get along without her name ; they 
might take the land, but she would sign nothing. She had no 
reason, except that she would not put her name to the paper 
in question. 

In a few instances that have come under my observation, 
intense animosities have been engendered on the part of senile 
dements toward relatives and friends, and especially children. 
I have known a patient to deliberately inveigle a young child 
into approaching her closely, and then to seize her and pull 
her hair, pinch and scratch her. The like tendency to injure 
relatives and friends is sometimes shown in the disposition 
they make of their property by will. It is always a suspi- 
cious circumstance, indicating mental alienation of some kind, 
and in old people usually senile dementia, when such persons 
leave their estates away from those who have taken care of 



596 DESCRIPTION AND TREATMENT OF INSANITY. 

them, or with whom, up to recent dates, they have been on 
terms of affection, to missionary societies and other organiza- 
tions of the kind. 

In senile dementia there are occasionally periods of ex- 
citement approaching acute mania in their intensity, during 
which' there are illusions, hallucinations, and delusions, with 
impulsions to the perpetration of acts of violence. Again, 
there is, especially in men, not infrequently a reawakening 
of the sexual appetite, and as the instinct is not controlled 
to a sufficient extent by the reason, and as the power is rarely 
restored to an extent commensurate with the desire, various 
indecent and immoral acts, coming under the head of what 
Tardieu 1 calls attentats aux mosur$, are committed. The 
records of the police courts abound with cases of the kind, in 
which old men are accused of obscene conduct with little girls 
and boys, and in which the existence of senile dementia can 
often be pleaded in extenuation. 

The course of senile dementia, resulting as it does from re- 
gressive changes in the brain-tissues, is progressively onward 
to complete mental annihilation and eventually death. 

i — GENERAL PARALYSIS. 

The affection now known as general paralysis, general 
paralysis of the insane, general paresis, paralytic dementia, 
and other names, was first described, though imperfectly, by 
Delay e, 2 in 1822 ; then more thoroughly by Bayle, 3 in the same 
year ; and finally, with much more completeness and exactness, 
by Calmeil,* in 1826. Although cases of insanity presenting 
the symptoms of general paralysis had been observed by sev- 
eral alienists, no one before the three writers whose names are 
here given had differentiated the affection from others, and 
raised it to the position of a distinct pathological entity. 
Since then it has been still more thoroughly studied, mainly 
as before by French alienists, who have in this, as in psycho- 
logical medicine generally, occupied the first place, till now it 
is probably the best known in its symptoms, pathology, and 

1 " Etude medico-legale sur les attentats aux moeurs," 7 e edition, Paris, 
1878. 

2 " De la paralysie generale, incomplete," These de Paris, 1822. 

3 " Recherches sur les maladies mentales," Paris, 1822, and " Traite des mala- 
dies du cerveau et de ses membranes," Paris, 1826. 

4 "De la paralysie consideree chez les alienes," Paris, 1826. 



GENERAL PARALYSIS. 597 

especially its morbid anatomy, of all the forms of mental de- 
rangement. 

General paralysis is a very common mental affection, the 
most common perhaps of all, and, aside from the implication 
of the mind, presents the very striking feature of a gradually 
advancing loss of motility. On account of the fact that the 
paralysis involves sooner or later nearly every muscle of the 
body, it is called " general." This paralysis may show itself 
at the same time that the insanity is manifested ; it may pre- 
cede the mental derangement, or it may be subsequent thereto. 
The latter is much the more usual order. Although some of 
the more striking phenomena of general paralysis may appear 
with suddenness, there is nearly always a prodromatic period, 
during which there are symptoms, perhaps not very decided, 
of the morbid changes going on in the brain. 

The most suspicious of all the circumstances, which may 
indicate the inception of general paralysis, is a gradual but 
obvious alteration in the mental characteristics of the indi- 
vidual. He does things which are not in accordance with his 
disposition or faculties of the mind as they have previously 
been manifested. He forms relations, often with women, 
which are matters of surprise to those who have long known 
him ; he contracts friendships with persons whom every one 
is certain he would have avoided but for the change which is 
coming over him ; he makes investments such as no pru- 
dent man would make ; he alters the details of his business, 
dismisses his best employees, who have been with him for 
years, and engages others whom he scarcely knows. 

A weakening of the principles of morality, which the indi- 
vidual may previously have held, is also often among the 
prodromatic symptoms of the disease. He may, therefore, 
perpetrate frauds of various kinds — generally, however, of no 
very great extent — or commit obscene acts, under circum- 
stances which are. almost certain to result in detection; or, 
what is perhaps still more common, he pilfers whatever he 
can lay his hands on, and without adopting the means of 
precaution which the common thief would use to prevent dis- 
covery. Moreover, the articles he steals are not in general of 
any use to him, and are thrown aside as soon as he has them 
in his possession. Many distressing instances of general 
paralytics, of the highest respectability, being arrested for 
petty thefts have been reported, and several such have come 



598 DESCRIPTION AND TREATMENT OF INSANITY. 

under my own observation. In one of these, the patient, an 
eminent lawyer, who had at one time been on the bench, was 
detected in stealing engravings from a picture-dealer. He 
was walking out of the shop with the prints rolled up under 
his arm, and had got out of the door before it was discov- 
ered that he had stolen instead of having bought the pictures. 
In another instance, a gentleman repeatedly stole the silver 
forks and spoons from the tables at which he was invited to 
dine, and was at length detected with a silver sugar-bowl in 
his coat-pocket ; and a third limited his depredations to 
books, which he took from several libraries and shops of this 
city. In all these persons, unmistakable symptoms of gen- 
eral paralysis were subsequently developed. 

The relation between reasoning mania and general paral- 
ysis has been referred to when the first-named affection was 
under consideration. That it not infrequently results in 
general paralysis I am quite sure, and hence it may be re- 
garded as sometimes the prodromatic stage of the more pro- 
nounced disease. 

A general state of exhilaration, different from the patient's 
ordinary manner and feeling, may exist for several months or 
even years before any more obvious symptom makes its ap- 
pearance. No one in his own opinion was ever in a better 
state of health than he, no one more successful in business, 
no one with better surroundings, or more intelligent or affec- 
tionate children. While this state is not exactly the delirium 
of greatness, which forms so prominent a feature of general 
paralysis at a later stage, it is, doubtless, the forerunner of 
that symptom. 

Among the physical prodromata are pain in the head, ver- 
tigo, insomnia, localized paralysis, and attacks of bodily 
weakness. Ptosis is occasionally met with, as is also in- 
equality of the pupils. I have known of two cases in which 
the pupil of one eye was dilated for seven and six years 
respectively, before there were any other notable symptoms 
than the exhilaration to which reference has just been made. 

Twitchings of the muscles of the face are frequently met 
with in association with other prodromata. 

It is usual with writers on general paralysis to divide the 
phenomena of this disease into three, four, or even more 
periods. It is difficult, if not impossible, to do this with any 
degree of accuracy, as the several stages constantly run into 



GENERAL PARALYSIS. 599 

each other, and even alternate in the same patient. There is 
nothing either to be gained on the score of clearness of de- 
scription by snch a course, and I shall therefore disregard it 
and describe the disease as the symptoms ordinarily present 
themselves, pointing out at the same time the irregularities in 
the progress of the affection that are most apt to occur. 

Occasionally there is no prodromatic stage, but the affec- 
tion begins with an attack of congestion of the brain, during 
which there is delirium and the other phenomena, more or 
less modified, of an attack of acute mania ; or the first mani- 
festation may be an epileptiform convulsion. 

During both of these forms of seizure, there are often 
spasms and paralyses, the latter generally restricted to the 
muscles of the eye, the tongue, or the face. 

Or these attacks may follow the prodromatic stage, and 
usher in the more pronounced symptoms of the disease. 

They may be repeated several times, but are usually ap- 
parently completely recovered from, and the patient goes 
about his ordinary business, and transacts it with a marvellous 
degree of exactness in all its details. 

Mental Symptoms. — Among the earliest of the mental 
symptoms generally noticed, when the disease is fully estab- 
lished, is an excessive anxiety in regard to matters which are 
really of no great importance, or which are of altogether 
imaginary importance. In one of the cases that have come 
under my care, this symptom was shown by a morbid appre- 
hension on the part of the patient that he was not managing 
some trust funds in the best possible way ; in another, by the 
idea that he was constantly wounding the feelings of his 
friends ; another was continually changing his mind about 
the most trivial things, and apparently thinking that the 
world watched with great anxiety all his movements ; another 
thought that he had given syphilis to his wife, and that he 
saw the evidences of the disease on her person. He accord- 
ingly experienced the most poignant remorse, and spent the 
greater part of his time in self-reproaches and lamentations. 
He had had syphilis, but there was no reason to think that 
he had infected his wife ; and in another case the patient, who 
had all his life been a speculator in stocks, suddenly became 
impressed with a keen sense of the wrong of which he had 
frequently been guilty, and spent hours in devising imprac- 
ticable schemes for making restitution. 



600 DESCRIPTION AND TREATMENT OF INSANITY. 

In the beginning the general mental type is in most cases 
that of depression. The emotions are easily excited, and the 
delusions which soon make their appearance are of the melan- 
cholic form. The idea of propriety in the every-day affairs 
of life seems to be lost, and the patient will commit all kinds 
of indecent acts without appearing to be aware that he is 
doing anything unusual. He becomes regardless of his per- 
sonal appearance, neglects to change his linen, appears in 
public half dressed, and indulges in other similar conduct, 
when previously he has been noted for scrupulous attention 
to all matters of cleanliness or etiquette. His memory fails 
rapidly, and his intellectual vigor is lessened from the first. 
At the same time he is often quarrelsome and disputatious, 
but, not being able to convince others of the truth of his ideas, 
he attacks with physical force those who venture to differ 
with him. His acts are in other respects eccentric and absurd. 
He spends money in things which are of no manner of use to 
him, and at the same time neglects to pay his small debts. 
A patient of mine sent home a wagon-load of snow-shovels, 
another bought a dozen sets of weights and measures, another 
sent out agents into the country and purchased all the turkeys' 
eggs he could get, and another drained the florists of tulip- 
bulbs. He harasses in every way those who are about him, 
gives them impossible orders, and then abuses them if they 
are not at once obeyed ; he is whimsical at his meals, his likes 
and dislikes are changed without adequate reason, and he 
either eats and drinks voraciously or declares that nothing is 
cooked to suit him, and leaves the table in a rage. At times 
he sheds tears over the veriest trifles, and often for no reason 
that he can allege. 

This state of depression is not of very long duration, nor 
is it always well marked in its manifestations. So far as my 
experience goes, it is, however, almost invariably the earliest 
mental state of the fully established disease, either when there 
has or has not been a prodromatic stage. It is always accom- 
panied by those physical symptoms so characteristic of general 
paralysis, and to which attention will presently be directed. 

In some cases the depression becomes more profound, and 
a state of fixed melancholy, characterized by delirium, in 
which there are varied illusions, hallucinations, and delusions 
of a distressing or terrifying nature, is established. This may 
constitute the essential mental feature of the disease, but is 



GENERAL PARALYSIS. 601 

by no means so frequent a type as its opposite, that of ex- 
hilaration. It will be more fully considered further on, as one 
of the irregular forms. 

In the vast majority of cases the slight mental depression 
which exists in the beginning of general paralysis disappears 
either suddenly or gradually, and exaltation takes its place. 
The patient becomes more cheerful, forms all kinds of impos- 
sible schemes for suddenly acquiring great wealth, and these 
are quickly abandoned for others equally impracticable. One 
man proposes to buy up all the water-power in the United 
States, and let it out to applicants at high prices. He makes 
a table showing, in his opinion, where the power is, its capa- 
city, the price for which it can be obtained, and an estimate of 
the sum for which it can be leased to manufacturers. The 
profits by his exhibit amount to over a hundred millions of 
dollars a month. Another is going into the ship-building 
business, and intends to construct vessels capable of carrying 
ten thousand cabin-passengers each, and of making the voy- 
age to Europe in twenty-four hours ; and a third has printed 
the prospectus of a company he is about organizing, to ac- 
quire from the principal governments of the world the exclu- 
sive right to manufacture India-rubber rattles. I cite from a 
printed copy a few paragraphs from this document : 

" Everybody, from the infant in arms to the decrepit old 
man, likes to make a noise in the world. Those who object 
are a few nervous individuals, who do not know what is good 
for them. The noise that should be made is a gentle, undu- 
lating, penetrating, but not irritating jingle. Experiments 
have shown that such a noise properly applied has all the 
soothing influence of opium and chloral without their dan- 
gers. I have established the fact, after the expenditure of 
over ten millions of dollars, that the best rattles for the pur- 
pose of accomplishing the objects in view are made by a sil- 
ver sleigh-bell enclosed in a hollow India-rubber sphere, to 
which, for convenience, a handle of the same material is to 
be affixed. Thus constructed, the rattle in the hands of either 
infancy or old age, the youth or the adult, the maiden or her 
lover, the old maid or the bachelor, the widow or the widower, 
the barbarian or the civilized man, the king or the subject, 
the gentleman or the ruffian, the honest man or the thief, the 
Christian or the Jew, the saint or the sinner, the gentleman 
or the blackguard, the moral man or the hardened wretch 



602 DESCRIPTION AND TREATMENT OF INSANITY. 

who panders to the most depraved appetites of the scoun- 
drels who fatten on the life-blood of the people— all, all, all 
must have the India-rubber, health-giving, and mind-soothing 
rattle. 

" The undersigned has devoted over two hundred and 
fifty years, both in this world and in a former state of exist- 
ence, to the investigation of the properties of India-rubber 
and silver. He has ascertained, after many failures in his 
experiments, and the expenditure of over twenty millions of 
dollars, that they exercise health and life giving properties to 
all men. Rattle and you will live, rattle and you will be 
happy, rattle and you will prosper, rattle and you will be 
successful, rattle and you will be able to procreate more chil- 
dren than the universe can contain. 

"A company must be organized to carry out the benefi- 
cent objects which the undersigned has in view. No sub- 
scriptions in money are required, as he has taken all the 
stock, to the extent of one thousand millions of dollars. He 
is now making contracts for all the rubber the world can pro- 
duce, and is about buying two hundred of the richest silver- 
mines in the world. Every man, woman, and child on the 
face of the earth will require several rattles, for, by varying 
the tone of the bell, different properties are given to the rattle, 
and hence the same rattle will not do for every person or for 
every purpose. Come up, therefore, and aid in this grand 
undertaking in which profits of thousands of millions of dol- 
lars will be made every year, and the human race rendered 
happy." 

There was a good deal more in the same strain. As will 
be perceived, the prospectus is written in good language, and 
is coherent. Later, this gentleman was unable to string to- 
gether ten words in a logical manner, or to spell the simplest 
words correctly. 

Thus, delusion after delusion rapidly succeed each other, 
and these in the great majority of cases relate to the gran- 
deur, the wealth, the physical strength, or some other great 
quality of the patient, constituting the delire de grandeurs 
of the French. One will tell of his immense palaces, built 
of gold and inlaid with precious stones, and in the next 
breath will descant of his great wealth, or his extreme light- 
ness, or of the number of children he has, or of the millions 
of operas he has composed. Another urges his great impor- 



GENERAL PARALYSIS. 603 

tance in the political world ; tells us that he has elected all 
the members of Congress himself, that he has paid off the 
national debt, and that, in consequence, he is to be made Em- 
peror of the United States, with a salary of a thousand mill- 
ions a year ; that he is going to have a thousand physicians, 
who are to be clothed in blue-velvet uniforms, embroidered in 
gold and diamonds ; that he has chartered the Great Eastern 
for a pleasure-trip, and engaged ten thousand musicians, and 
a similar number of ballet-dancers, to go with him. The next 
day he has forgotten all these fancies, and is off on another 
series of absurd ideas. In no respect is he restrained in the 
extent of his delusions ; impossibilities are not regarded. 
While scarcely able to drag one leg after the other, he will 
brag of his great fleetness of foot, and in the very death-gasp 
will mutter about his extreme strength and endurance. 

But while the general paralytic is not confined to the 
limits of possibility in the delusions of grandeur which he 
entertains, and which, at this period of his disease, form its 
chief feature, it has appeared to me that he very rarely (never 
in my experience) imagines that he has assumed any super- 
natural or extra-mundane personality. He is never God, or 
Christ, or an angel, except so far as he, John Smith, for in- 
stance, may be God, or Christ, or an angel, without change 
of personality ; indeed, it is scarcely ever the case that 
he assumes to be any other person than he really is. He will 
imagine himself to be a general, a king, an emperor, or as 
occupying some other great office, but he is always himself. 
It is he, in his own person, who is the grand personage, and 
this fact is made to appear in all that he says and does. 

The following "proclamation" was issued by a general 
paralytic, and given to me by his brother, when the patient 
came under my charge. Nothing could be a better example 
of the exaltation of sejf to which I refer, or of several other 
points to which attention will presently be drawn : 

" To all the People and Inhabitants of the United States 
and all the outlying Countries, Greeting : 

"I, John Michler, King of the Tuskaroras, and of all the 
Islands of the Sea, and of the Mountains and Valleys and 
Deserts ; Emperor of the Diamond Caverns, and Lord High 
General of the Armies thereof ; First Archduke of the Beau- 
tiful Isles of the Emerald Sea, Lord High Priest of the Grand 
Lama, etc., etc., etc. : Do issue this my proclamation. Stand 



604 DESCRIPTION AND TREATMENT OF INSANITY. 

by and hear, for the Lord High Shepherd speaks. No sheep 
have I to lead me around, no man have I to till me the ground, 
but the sweet, little cottage is all of my store, and the room 
that I sleep in has ground for the floor. No chair have I to 
sit myself down, no meat have I to eat myself down, but the 
three-legged stool is the chief of my store, and my neat little 
cottage has ground for the floor. ]STo children have I to play 
me around, no dog have I to bark me around, but the three- 
legged stool is the chief of my store, and my neat little cot- 
tage has ground for the floor. 

u Yea, verily, I am the Mighty King, Lord Archduke, 
Pope, and Grand Sanhedrim, John Michler. None can with 
me compare, none fit to comb my hair, but the three-legged 
stool is the chief of my store, and my neat little cottage has 
ground for the floor. John Michler is my name. Selah ! 

"I am the Great Hell-Bending Rip-Roaring Chief of the 
Aborigines ! Hear me and obey ! My breath overthrows 
mountains ; my mighty arms crush the everlasting forests 
into kindling-wood ; I am the owner of the Ebony Planta- 
tions ; I am the owner of all the mahogany groves and of all 
the satin-wood ; I am the owner of all the granite ; I am the 
owner of all the marble ; I am the owner of all the owners 
of Everything. Hear me and obey ! I, John Michler, stand 
forth in the presence of the Sun and of all the Lord Suns and 
Lord Planets of the Universe, and I say, Hear me and obey ! 
I, John Michler, on this eighteenth day of August, 1880, do 
say, Hear me and obey ! for with me none can equal, no, not 
one, for the three-legged stool is the chief of my store, and 
my neat little cottage has ground for the floor. Hear me and 
obey ! Hear me and obey ! John Michler is my name. 

" John Michler, First Consul and Dictator of the World, 
Emperor, Pope, King, and Lord High Admiral, Grand Licon- 
thropon forever ! " 

In addition to the exaltation exhibited by this production, 
it is also seen that there are several anti-climaxes in the as- 
sertions of the writer. This is a feature I have repeatedly 
noticed. Several of Dr. Mickle's ' patients exhibited the like 
peculiarity. Thus, one said : " My father made all the cloth- 
ing for the army ; my mother was a lady in her own right, 
and took in washing." Another declared he could "speak 
two Indian languages, and had a dozen pairs of socks." 

1 " General Paralysis of the Insane," London, 1880, pp. 227, 235. 



GENERAL PARALYSIS. 605 

In a somewhat early stage of the disease, but yet one which 
exhibits the sensory and motorial phenomena characteristic 
of the disease, it is difficult to decide with certainty whether 
or not the ideas expressed by the patient are facts, delusions, 
or lies. They relate to his prowess in various fields, to his 
great influence and standing in society, and to the schemes 
which he has set on foot, but at the same time they do not 
pass the limits of possibility. For all that the examiner can 
tell by taking them only into consideration, they may be true, 
they may be false beliefs, or they may be deliberate lies, told 
either with the intention of deceiving or simply from a love 
of lying. Generally, however, but little difficulty will arise, 
for there are other circumstances which are sufficient to es- 
tablish the point of sanity or insanity, and usually the stories 
themselves are of such a character that no sane man would 
relate them. Thus, in a case which I saw in conjunction with 
Dr. Meredith Clymer, the patient had inequality of the pu- 
pils, fibrillary contractions in the tongue, and a titubating gait. 
He had been violent on several occasions, had spent large sums 
of money in excess of his means, and for things of no use to 
him ; he had committed various offences against decency, and 
had previously been in a lunatic asylum. When, therefore, 
he informed us that, at eight years of age, he had seduced his 
cousin ; that his son, eleven years of age, had seduced the 
two daughters of one of the richest bankers in New York — 
being, therefore, as he said, "a chip off the old block" ; that 
he was one of the editors of a prominent newspaper of this 
city ; that many ladies, some of them of the highest standing, 
had fallen in love with him, besides detailing with the ut- 
most minuteness the particulars of various obscene acts which 
he and others had practiced — it did not much matter whether 
they were facts, lies, or delusions. They were all, perhaps, 
within the limits of possibility, but their improbability was 
such that the question of their truth was not worth considering. 
From any point of view they were equally good evidence of 
the person's insanity, for no sane person would have men- 
tioned such things had they been true, or have lied in that 
style to two physicians who, he knew, were inquiring into his 
mental condition. Although pronounced sane by a sheriff's 
jury, composed of men supposed to be of more than the aver- 
age juryman's intelligence, his subsequent conduct was of such 
a character as to prevent the judge confirming the finding. 



GOG DESCRIPTION AND TREATMENT OF INSANITY. 

A tendency to erotic delusions, almost reaching to the ex- 
tent of satyriasis, and a marked increase in sexual appetite 
and power, are often witnessed, as in the case just cited. The 
whole conversation of the patient is of a libidinous character, 
and he may attempt acts of violence in accordance with his 
delusions and augmented venereal instincts, or form illicit re- 
lations with one woman after another, or descend to almost 
continual masturbation. 

The whole manner and bearing of the patient are in ac- 
cordance with the exaltation of which he is the subject. He 
is all good-nature and smiles, he makes , friends with those 
around him, lets them into all his plans, and freely com- 
municates his delusions. He bustles about noisily, whistles 
and sings — but wofully out of tune — inflates his lungs and 
slaps his chest, in the feeling of Men etre which governs him. 
But there are periods when reaction occurs, when he shuns 
those with whom he has consorted, and quarrels with those 
about him, and when he is a prey to fits of mental depression 
almost attaining to melancholia. The patient whose case I 
have just given, only a few days after his discharge from the 
asylum, pointed a loaded pistol at and threatened to kill a 
man who did not do a piece of work according to his fancy. 
And instead of the great exaltation of the ego which I have 
described, there may be a more subdued condition, in which, 
while there is abundant evidence of the self-sufficiency which 
actuates the patient, there is not that swelling pride and 
vanity which lead him into the most preposterous delusions. 
His fancies are of a quieter kind. He is strong, in good 
health, " never felt better," can walk a dozen miles and feel 
no fatigue, has all the money he wants, is ready to lend to 
all who ask, is capable of filling the highest offices, can drink 
any quantity of champagne without getting intoxicated, can 
write better novels than Scott or better poetry than Byron, is 
going to write a play that will eclipse anything Shakespeare 
ever produced, is the best actor that ever trod the stage, and 
so on, ad infinitum. At times, however, there are apt to be 
paroxysms of a higher degree of exaltation, when there are 
delusions without limit, and the impossible is in the ascendant. 

Billod ' has described a form of mental derangement some- 
times met with in general paralytics, in which, while the pa- 

1 " Recherches sur la paralysie generate des aliens," Ann. rned.-psychol., Oc- 
tober, 1850 ; also, " Des maladies mentales," Paris, 1882, p. 300. 



GENERAL PARALYSIS. 607 

tient lias the most correct ideas relative to Ms estate and so- 
cial position, lie has delusions only in regard to his capacity 
or some other personal trait. He relates an anecdote of an in- 
terview between M. Moreau, physician to the Bicetre, and a 
general paralytic, which took place in his presence. The 
physician asked all the questions which could possibly eluci- 
date the condition and the character of the delusion exhibited 
by the patient. The replies were modest, reasonable, and cor- 
rect ; he admitted that he was poor, of humble origin, without 
position, of little more than ordinary intelligence, and that he 
had no other resources than those which came from his trade 
of tailor. The able physician of the Bicetre almost despaired 
of finding any defect in his reasoning processes, when the 
idea struck him to ask if he was well skilled in his art. " Oh, 
yes," he answered, with that emphasis peculiar to paralytics, 
"I am the greatest tailor in the world." 

In a case under my own charge, the patient, who had all 
the prominent physical symptoms of general paralysis, ex- 
hibited no delusions except in regard to the one point that 
his eyes were of such extreme perfection that he could see 
the smallest objects at immense distances, could see through 
substances which to others were opaque, and that no micro- 
scope could equal them in the power to see minute bodies. 

Another form, also described by Billod, ' is characterized by 
the existence of apparent mental integrity, except in the fact 
that the subjects are abnormally vain of the qualities they 
possess or of the acts they have accomplished. They boast, 
but they boast of small things, which, though of no impor- 
tance actually, are immense in their eyes. A physician, a 
general paralytic, exhibited this condition. After the most 
searching investigation, no delirious conception was discov- 
ered. He was modest, without fortune, of abilities which he 
took at their real value, and had no delusion of any kind. 
"But," said he very often, "the year 1844 was a great year 
for me; I made a great deal of money that year." "How 
much did you make?" "Eighteen hundred francs," he an- 
swered, with emphasis. 

As I have said, the form may be continuously of the mel- 
ancholic type, or there may be paroxysms of intense mental 
depression, in which there are illusions, hallucinations, and 
delusions occurring sporadically, as it were, or alternating 

1 Op. cit., p. 301. 



COS DESCRIPTION AND TREATMENT OF INSANITY. 

regularly with periods of excitement, as in circular insanity. 
Thus Calmeil l reports several cases of general paralysis, which 
were characterized by mental depression instead of by mental 
exaltation. Other writers, and especially Baillarger, 8 have 
described the melancholic variety. Lunier 3 attributes its 
more frequent existence at the present day than formerly to 
a change of type which the disease like others has undergone 
in consequence of different hygienic conditions and habits. 
Billod 4 describes it at length, and MM. Voisin and Burlu- 
reaux 6 have produced an exhaustive monograph on the sub- 
ject. These latter go so far as to declare that depression is 
met with in a greater number of cases than is exaltation. 
Although this statement is not in accordance with the results 
of my own experience, and is probably not correct as regards 
this country, I am satisfied that the melancholic type is much 
more common than is generally supposed, or than insane asy- 
lum superintendents would have us believe. 

The form in question may show itself as simple melan- 
cholia, with or without a tendency to suicide. Cases of this 
kind have been adduced by Calmeil, 6 Lunier, 7 Baillarger, 8 
Voisin and Burlureaux, 9 and others. In this variety the in- 
tellect is not in the early stage markedly affected, though it 
has lost its strength, and ideas come slowly. It is as regards 
the emotions that aberration is chiefly to be observed. The 
patient is full of self-reproaches, avoids all companionship 
with others, thinks himself only fit to die, but is nevertheless 
full of apprehensions relative to the future life. 

This, however, is only the first stage, for eventually de- 
lusions, often based on illusions and hallucinations, make 
their appearance, and the state is not essentially different 

1 " Paralysie consideree chez les alienes," Paris, 1826, p. 243 et seq. 

2 " Nouvelles considerations sur la paralysie progressive incomplete," "De 
la melancholie avec stupeur," Paris, 1846, and Gazette des Ropitaux, 1857. 

3 Annates medico-psychologiques, jnillet, 1873. 

4 " Recherches sur la paralysie generale des alienes," Ann. med.-psy. y October, 
1850, and "Des maladies mentales," Paris, 1882, t. i, p. 308. 

6 " De la melancolie dans ses rapports avec la paralysie generale," Paris, 1880. 

6 " Traite des maladies inflammatoires du cerveau," Paris, 1859, cases xx, 
xxii, and xxiv. 

7 " Recherches sur la paralysie generale progressive," Ann. med.-psychol, 
t. i, p. 1, 1849. 

8 " Des sympt6raes de la paralysie generale." appendice au " Traite des mala- 
dies mentales," par Griesinger, Paris, 1865. 

9 Op. cit., p. 50 et seq. 



GENERAL PARALYSIS. 609 

from that of melancholia with delirium, already described, 
though perhaps never reaching the high degree of intensity 
attained in that affection. 

Or the condition may be that of melancholia with stupor, 
the patient refusing to talk, and sitting or lying hour after 
hour with scarcely the motion of a limb. During either of 
these states there may be strong tendencies to suicide or to 
mutilation of the person. 

Again, the type of melancholia is that of hypochondria, 
which, beginning from perverted sensations in various parts 
of the body, goes on with gradually increasing force till de- 
lusions of the most ridiculous character fill the mind of the 
patient. One imagines that his bowels are gone, another that 
his insides are passing away with his fseces, another that his 
anus is hermetically sealed, another that his tongue has dis- 
appeared, and so on through the whole range of impossibili- 
ties. Any one patient may in his own person be the subject 
of any number of delusions, following each other with a de- 
gree of rapidity so great that one is scarcely gone before the 
other has made its appearance. A patient of my own within 
the space of half an hour conceived that he was made of raw 
cotton, that his arms were absent, that he had no nose, that 
his penis had been turned inside out, and that he had per- 
petual spermatorrhoea. The delirium of negation, x to which 
reference has already been made when the subject of hypo- 
chondriacal melancholia was under consideration, is espe- 
cially common in the hypochondriacal form of general paral- 
ysis, and the patients conceive that they have lost various 
parts of their bodies. A general paralytic affected in this 
manner will, in the course of a single day, conceive that he 
has lost every limb and organ. One of my own patients, a 
physician, thought that every part of him was gone except 
his tongue and the posterior part of the third frontal convo- 
lution. He was therefore able to talk, but could do nothing 
else, and lay all day with his eyes closed, perfectly motion- 
less, but answering promptly every question put to him. 

Again, there may be, especially in women, the micromania- 
cal delusion (delire micromaniaque), which has also been re- 
ferred to under the head of hypochondriacal melancholia. In 
these cases, the patients think themselves much smaller than 

1 "Du delire des negations," par M. Cotard, Archives de neurologie, No. 11> 
1882, p. 152. 



610 DESCRIPTION AND TREATMENT OF INSANITY. 

they really are, like infants, dwarfs, or dolls. Others imagine 
that their limbs have been rednced in size. 

Moreau ' (de Tonrs) refers to the case of a patient who felt 
his body get smaller and smaller till it did not exceed two 
feet in height. 

A lady, the subject of general paralysis, in which the 
mental phenomena were of the depressant form, imagined 
that her month was so small that a spoon would not go into it. 
At last it reached, as she thought, such minute dimensions 
that no solid food could be taken, and she insisted on being 
fed through a small glass tube and with liquid food only. 
And in both forms, that of exaltation and depression, there is 
a notable impairment of the intellect, so far as its force, its 
majesty, and its ability to comprehend are concerned. The 
patient affected with general paralysis passes, perhaps slowly, 
but with almost absolute certainty, to a condition of dementia. 
His memory, his judgment, his power of application, are weak- 
ened from the first. Long- sustained thought on any one sub- 
ject is impossible with him. He is argumentative, but his 
arguments are feeble and illogical, and sometimes he has 
enough mind to perceive this fact, and to express chagrin at 
the circumstance. 

Physical Symptoms. — In my experience, the first sign of 
loss of power — one which is sometimes observed before any 
evidence of mental derangement is perceived — is a slight 
defect of articulation, due to paralysis of the lips. At first 
this is scarcely perceptible, there is merely a little trembling, 
an action such as is seen in persons who are endeavoring to 
restrain their emotions, but it is sufficient to give indistinct- 
ness to the utterance of those words which contain labial let- 
ters, and to impart a peculiar hesitancy or tremulousness to 
the speech. 

The tongue is the next organ concerned with speech to be 
affected. Examination shows that there are fibrillary con- 
tractions of its muscles, and that it is moved with less facility 
than in the healthy state. The articulation is slow, words are 
slurred over, and there are both stammering and stuttering ; 
owing to the weakness of the tongue, it cannot readily be 

1 " Du delire hypocondrique et de la paralysie generale des alienes," Bulletin 
de Vacademie imperiale de medecine, t. xxvi, 1860-1861, p. 191. The extract 
from this memoir published in the Bulletin does not refer to this case, but it is 
cited by MM. Voisin and Burlureaux. 



GENERAL PARALYSIS. 611 

raised to the roof of the month or pressed with sufficient force 
against the npper teeth, and hence there is a peculiar diffi- 
culty in enunciating words containing what are known as 
the lingual letters. The words " National Intelligencer" are 
almost impracticable to the general paralytic, and in trying 
to pronounce them he concentrates his whole attention on the 
act. Generally, he notices his defective articulation, and in 
endeavoring to correct it makes matters worse. His inability 
to be correct contrasts strongly with his violent efforts. Grad- 
ually, the paralysis of the tongue becomes more complete, 
and at last this organ can only be moved with great difficulty 
and very imperfectly. The other facial muscles participate, 
and there is a blank, somewhat sorrowful expression always 
present. 

At the same time, when the muscles of the face are in 
action, there is often an exaggerated degree of motility, a 
motility not in consonance with the emotions or the absence 
of all emotion, in logical accord with the thoughts as ex- 
pressed by the speech. The patient appears to be aware that 
his facial muscles are deranged in their action. Instead, there- 
fore, of allowing them to act automatically, as in the normal 
condition, without a thought as to their mode of action, he 
brings his will to bear upon them when he speaks, and as a 
consequence there is excessive motility. He does more with 
them than is necessary. I have seen the general paralytic, 
while expressing the most indifferent ideas, throw the muscles 
of his face into such extensive action that he had the appear- 
ance of a person laughing, so far as the countenance was con- 
cerned. He was like the child suffering with chorea, who 
attempts to pick up a pin. All the muscles of the body are 
thrown into action by the effort. 

The muscles of deglutition are involved at an early stage of 
the disease, and hence there is difficulty of swallowing. The 
alimentary bolus is not grasped with firmness, and the paral- 
ysis of the tongue and of the temporal, masseter, pterygoid, 
and buccinator muscles prevent the due mastication of the 
food, and the propulsion of the mass toward the pharynx. In 
consequence of these troubles, choking is apt to occur, and 
this is rendered a still more probable circumstance by the 
fact that the sensibility of the lining membrane of the fauces 
is so diminished that no adequate idea of the quantity of food 
in the mouth is obtained. Hence more is taken in than can 



612 DESCRIPTION AND TREATMENT OF INSANITY. 

be swallowed, and a plugging up of the pharynx is the result, 
with suffocation, if relief be not afforded. I have known of 
several narrow escapes from death by this cause. 

At a later period there are notable changes in the voice. 
It becomes nasal, like that of a person whose nostrils are 
stopped up, and, moreover, loses its inflections, degenerating 
into a kind of monotone. These changes are due to the paral- 
ysis of the palate and pharynx, and, as remarked by Luys, ' 
are signs of great importance, as indicating the implication of 
the medulla oblongata in the morbid processes. 

Another derangement of phonation is that which results 
from paralysis of the vocal cords, and which, though I have 
observed it in many cases, has not attracted the attention it 
deserves from writers on general paralysis. The voice be- 
comes reedy, cracked, and this change is especially noticed 
if the patient can be induced to sing. It was observed to per- 
fection in a general paralytic whose case, as it involved some 
medico-legal questions, I brought before the New York 
Medico-Legal Society some three years ago. This patient 
had, among his other delusions of exaltation, the idea that he 
could sing with wonderful sweetness and power. He ran 
through, one after the other, dozens of popular airs from 
operas, but his voice had the peculiar reedy quality referred 
to, and broke at notes in the middle register. Moreover, 
every note was about half a tone flat. I was informed that, 
before the accession of his disease, his voice was of good 
quality, and that he was especially noted for singing in tune. 

As the results of numerous laryngoscopic examinations, 
Mr. Lennox Brown, 2 among other conclusions, established the 
facts that the reflex excitability of the pharynx is markedly 
diminished from the beginning of the disease, and that there 
is impairment of tension and of co-ordinate action in the vo- 
cal cords, unaccompanied by any distress of respiration. The 
first of these circumstances tends to make deglutition more 
difficult, as the act of swallowing does not receive its proper 
reflex excitation, and the second sufficiently accounts for the 
changes in the voice to which I have referred. 

Closely connected with speech is writing, and here again 
there are notable deviations from the standard of correctness. 

1 "TraitS clinique et pratique des maladies mentales," Paris, 1881, p. 564. 

2 "Laryngoscopic Observations in General Paralysis," West Riding Lunatic 
Asylum Medical Reports vol. v, 1875, p. 271, et seq. 



GENERAL PARALYSIS. 613 

The ability to write well, if previously possessed, is lost, and 
the patient not only exhibits a bad chirography, but omits 
letters from the words he uses, and words from the sentences, 
and in some instances appears to have forgotten how to spell. 
He seems to be guided in some cases by the sound of words, 
and hence spells them phonographically. In a letter which I 
recently received from a mercantile gentleman, affected with 
general paralysis, and who had been in an asylum, many 
words, of which it is quite certain he knew the proper orthog- 
raphy, were spelled apparently from the sound. " Pain in the 
knee " was u pane in the nee " ; " I shall try to see you next 
week" became " I shal tri to see you next weke " ; and " I 
take my medicine regularly every day " was " I take my medi- 
son regulaly every da " ; and yet at this time there was a de- 
cided remission in the violence of his symptoms, so far as his 
mind was concerned. 

The muscles of the eyes are also generally involved, pro- 
ducing ptosis from paralysis of the levator palpebrse superi- 
oris, diplopia from implication of the internal rectus, and dila- 
tation of the pupil — all of these being due to lesion existing 
at the point of origin or in the course of the third nerve — or 
the external rectus may be involved, causing diplopia from 
the implication of the sixth nerve. 

But the oculo-pupillary derangements are by no means 
restricted to a dilatation of the pupil on one side from the 
lesion of the third nerve. Both may be dilated ; one may be 
dilated and the other contracted ; both may be contracted ; 
and one may be contracted while the other remains in a nor- 
mal condition. Perhaps, of all the changes to which the pu- 
pils are subject, inequality, produced by the contraction of 
one pupil, is the most common, and this is due to paralysis of 
the sympathetic nerve. It is very rare that oculo-pupillary 
disturbances are not met with at some time in the course of 
general paralysis. The assertion of Austin, 1 that contraction 
or dilatation of the right pupil is associated with melancholic 
delusions, and contraction or dilatation of the left with ela- 
tion, is not in accordance with my experience, or with that of 
any one else, so far as I know. With the change in the size 
of the pupil, whether this be constriction or enlargement, 
there is almost invariably a sluggish condition of the iris, so 

1 " A Practical Account of General Paralysis, its Mental and Physical Symp- 
toms," etc., London, 1859, p. 34. 



614: DESCRIPTION AND TREATMENT OF INSANITY. 

that it does not respond normally to increase or diminution of 
light. This may be a phenomenon even when the pnpils are 
otherwise unaffected. 

Luys ' states that, under the influence of the emotions, and 
when the brain is in a state of increased activity, he has some- 
times seen a sudden contraction of one pupil and a dilatation 
of the other. 

Occasionally the outline of the pupil on one or both sides 
is irregular, but this is not a common phenomenon. 

The gait of patients affected with general paralysis is very 
peculiar, and is of two different kinds. In the one it is simi- 
lar to that of persons suffering with locomotor ataxia, and it is 
to this cause, as Westphal 2 has pointed out, that the de- 
rangement is due. The feet are lifted high, and are thrown 
down with a jerk, and with much force, the heel striking the 
ground first, and the sole coming down with a flop. As West- 
phal remarks, patients with this gait cannot stand with the 
eyes shut and the feet close together. The patellar tendon 
reflex is abolished. In fact, as Westphal 3 in a subsequent 
paper declares, the absence of this reflex is of itself sufficient 
to establish the existence of sclerosis of the columns of Bur- 
dach in conjunction with the cerebral lesions of general paral- 
ysis. 

And, again, the disturbances of locomotion and the mus- 
cular derangements generally, point to the occasional exist- 
ence of sclerosis of the lateral columns of the cord, and dis- 
seminated spinal sclerosis, as accompanying lesions of general 
paralysis. Cases of the kind have been observed by Claus, 4 
Schultze, 6 and Zacker. 6 In the case of a patient affected with 
general paralysis, now under my charge, there are delusions 
of grandeur, inequality of the pupils, disturbances of speech, 
and other cerebral symptoms of the affection, conjoined with a 
spastic condition of the lower extremities and frequent con- 
tractions of their muscles. In cases with this combination, 
the feet are scarcely lifted from the ground, but are shuffled 

1 Op. tit., p. 570. 

8 " Ueber den gegenwartigen Standpnnct der Kenntniss von der allgemeinen 
progressiven Paralysie der Irren," Griesinger's Archiv, Heft 1. 

3 Berliner Minischer Wochenschrift, i, 1881. 

4 Allgemeine Zeitschrift far Psychiatrie, 1878, p. 335. 

5 Archiv fur Psychiatrie, Band xi, p. 216. 

* Archiv fur Psychiatrie, Band xiii, p. 155. 



GENERAL PARALYSIS. 615 

over it, the walk being serpentine in character, progression 
being effected by the body being swung forward on the femur 
as each lower extremity is alternately on the ground. Owing 
to the contraction of the adductors, the legs frequently get 
interlocked, and walking is impossible. This is the case with 
the patient referred to. In him — and I presume the same is 
true of other similar cases — the patellar tendon reflex is 
greatly exaggerated. 

In other cases without accompanying spinal lesions, the 
gait is simply that of weakness. The patient staggers and 
stumbles and often falls, but there are no such disturbances 
as are met with in the forms just noticed. Hemi-paresis and 
hemiplegia, occurring in the course of general paralysis, are, 
as Mendel remarks, of temporary duration, unless they are 
the results of some organic associated condition, such as syph- 
ilis of the brain or cerebral haemorrhage. They are quite cer- 
tainly the consequences of the attacks of congestion of the 
brain to which general paralytics are liable. 

As regards the upper extremities, the fingers lose their 
deftness and delicate co-ordinating power. The handwriting 
is shaky, and there is awkwardness in buttoning the clothing, 
tying the cravat, and doing other things requiring exact ma- 
nipulations. The grip of the hand may still be strong, but 
there is an impossibility, as shown by the dynamograph, of 
maintaining a continuous muscular contraction for even a few 
seconds. The following is one of the tracings, made by a 
patient affected with the disease under consideration : 

Fig. 6. 




In analyzing this tracing, we see that it is not from feeble- 
ness of the muscles that the line is descending, for there 
are spasmodic elevations which show considerable force. It 



616 DESCRIPTION AND TREATMENT OF INSANITY. 

proves, however, that no matter at what point the pencil is 
placed, the patient cannot keep it there. 

Tremor is almost constantly present, not only abont the 
lips and tongue, as w r e have seen, but in the limbs also. It is 
most apparent when the patient attempts to perform a volun- 
tary movement, such as that of raising a glass of water to the 
mouth. It is also perceived when the hands are outstretched, 
or when the attempt is made to bring the two index-fingers 
together from opposite sides. 

Closely allied to tremor are the choreiform movements 
which occasionally occur in general paralytics, and which by 
some French and German writers have been supposed to be 
athetoic in character. As a matter of fact, they have no re- 
semblance to those met with in athetosis. The motions in the 
latter affection are slow, apparently deliberate, and always 
result in increased muscular development, while the chorei- 
form movements are quick, abrupt, do not lead to enlargement 
of the muscles, and are, in fact, only exaggerated tremors. 1 

The irritability of the muscles is, according to my experi- 
ence, lessened, from the very inception of the disease, to all 
kinds of electric excitation. Lowe 3 ascertained that, to the 
faradaic current in the muscles of the face in the earlier stages 
of the disease, there was neither exalted nor diminished excita- 
bility, but that in the last stage not only these muscles, but 
especially those of the lower extremities, presented decided 
loss of excitability. 

These results have been confirmed by Bevan Lewis, 3 who 
found in addition that the flexors of the foot were especially 
disposed to lose their electric excitability. 

On the other hand, Brierre de Boismont 4 arrived at the 
conclusion that the electric excitability to the galvanic cur- 
rent is not diminished ;. and Benedict 6 found it greatly in- 
creased in two cases that he submitted to examination. 

1 For a description of athetosis, the reader is referred to the author's "Trea- 
tise on Diseases of the Nervous System," first edition, 1871, and subsequent 
editions up to the seventh, 1881, New York. 

3 "On Electro-Excitability in Nervous and Mental Diseases," West Hiding 
Lunatic Asylum Medical Reports, vol. iii, 1873, p. 204. 

3 " On the Histology of the Great Sciatic Nerve in General Paralysis of the 
Insane," West Riding Lunatic Asylum Medical Reports, vol. v, 1875, p. 95. 

4 "Du diagnostic difFerentiel des diverses especes de paralysie gene>ale a 
l'aide de la galvanisation localisee," Annates medico-psychologiques, 1850, p. 603. 

6 Wagner's Archiv, Band viii, 1867, p. 140. 



GENERAL PARALYSIS. 617 

I have tested the electric excitability with a great many 
general paralytics using the galvanic, the faradaic, and the 
franklinic currents, and in all stages of the disease. The 
muscles of the face do not often show any impairment to the 
galvanic current, or to sparks from the franklinic machine, 
but the electric excitability to the faradaic current is generally 
markedly diminished. The muscles of the upper and lower 
extremities give like results to all forms of electricity, and 
this is most distinctly shown in those muscles which are 
farthest from the nerve-centres. 

Derangements of sensibility, general and special, are nota- 
ble symptoms of general paralysis, and consist both of anaes- 
thesia and of hyperesthesia. 

From the very earliest period anaesthesia is a phenomenon 
of general paralysis, and, according to De Crozant, 1 precedes 
all disorders of motility. It is general, but is not permanent, 
disappearing as soon as the disturbances of motility become 
well established. It is shown to all kinds of impressions — 
touch, pain, temperature — and patients often speak of the 
sensations of numbness which they experience, and which 
are those met with in other affections, "pins and needles," 
formication, and the feeling to which the term " asleep" is 
applied. 

At a later stage of the disease, though perhaps not so gen- 
eral in its distribution, it is more distinctly evident in locali- 
ties than it is in the beginning. Thus an arm or hand, one 
side of the face, and other parts may become its seat. Yoisin 
and Burlureaux 2 cite the case of a general paralytic, in whom, 
in the first stage, but for two days only, they discovered 
crossed anaesthesia, the limbs on the left side, and the face on 
the right being affected. This condition coincided with a 
state of great excitability. The patient was afraid ; heard 
discharges of fire-arms, and saw the devil. 

Hyperaesthesia is also often observed among the earliest 
phenomena. It takes the form of neuralgic pains, affecting 
the face, trunk, the limbs, or the viscera. Headache is gen- 
erally a symptom from the very beginning, occurring with 
more or less persistency throughout the whole course of the 
disease. It may be of all degrees of intensity, from a dull, 

1 " Note sur l'anaesthesie transitoire de la peau dans la periodes prodro- 
miques de la paraljsie generale," Ann. med.-psychol., 1847, t. i, p. 433. 
8 Op. cit., p. 203. 



r, 



CIS DESCRIPTION AND TREATMENT OF INSANITY. 

boring pain, as if produced by a blow with a blunt instrument, 
to tlie sharp sensation compared by some to the feeling which 
they suppose might be caused by the driving of a red-hot 
dagger into the brain. With these pains there are sometimes 
vaso-motor disturbances, the face and head being flushed and 
hot, and the ears particularly red and burning. Facial and 
cervico-occipital neuralgise are noli un common, and the electric- 
like or fulgurant pains, characteristic of locomotor ataxia, 
are met with in those cases complicated with this disease ; 
visceral pains are also common. In regard to the special 
senses, the phenomena are usually of the greatest importance. 
Beginning with that of smell, we find Yoisin * using this very 
emphatic language : 

"The diminution of the sense of smell on one or both 
sides is a sign of the greatest importance, and this is espe- 
cially the case as regards the prodromatic period. In fact, 
from the day that we establish the existence of a diminution 
of the sense of smell in a melancholic, all our doubts disap- 
pear, and we know that the patient not only will become a 
general paralytic, but that he already is one, when at the 
same time there may be no other somatic evidence of general 
paralysis." 

Although not able to endorse this opinion in its entirety, 
I am very well satisfied that the loss or diminution of the 
sense of smell on one or both sides is an important symptom 
in the early stage of general paralysis, and one, therefore, of 
much diagnostic value. As Yoisin further remarks, this 
deprivation is not met with in other forms of insanity save in 
exceptional cases, it being usually exaggerated if there be 
any change at all, and it exists from the very inception of the 
disease before there are derangements of speech, inequality 
of the pupils, or weakness of the memory. 

It is a sign easy to evoke. Some substance, the odor of 
which is known — I generally use a small vial of powdered 
camphor — is held to each nostril alternately, the other being 
closed, and the patient not being allowed to see what the 
substance is. Ordinarily, in cases of general paralysis, no 
odor is perceived ; in other cases it is mistaken for something 
else. During the remissions which take place in the course 
of the disease the sense of smell reappears. 

While not willing to say, from the results of my own 
1 " Traite de la paralysie g6n6rale des alien6s," Paris, 1879, p. 39. 



GENERAL PARALYSIS. 619 

experience, that every case of melancholia, in which the 
sense in question is abolished or perverted, is one of gen- 
eral paralysis, I am satisfied that a large proportion of gen- 
eral paralytics — probab]y nine tenths — exhibit the phenom- 
enon. 

On the other hand, Jehn 1 attaches no importance to Voi- 
sin's view. Of twenty general paralytics, he found but three 
in whom the sense of smell was notably affected ; in eleven, 
there was no change whatever. Mendel coincides with this 
opinion, not being able to find, even in the first stage of gen- 
eral paralysis, any confirmation of Yoisin's doctrine. Obvi- 
ously the matter requires further investigation. 

Atrophy of the olfactory nerves has been found in many 
cases of general paralysis. 

As regards sight, amaurosis and amblyopia are very com- 
mon throughout the whole course of general paralysis. The 
retina is easily fatigued even in the prodromatic stage, and 
vision becomes blurred or otherwise imperfect. Double vision 
from paralysis of the internal or external rectus muscle is 
also common. In several cases I have observed color-blind- 
ness on testing patients with Galezowski's color-scale. The 
chief difficulty experienced was in distinguishing green from 
red. Sometimes it was impossible to do so ; but, again, the 
patient could, by making an effort, arrive at a correct de- 
cision. In five cases there were various colored appearances 
— bluish- white, yellow, green, or red rings or disks, or halos 
of these colors — surrounding the objects looked at. In one 
case they completely filled the visual field. So far as I am 
aware, this condition of chromopsia has not been noticed by 
other writers on general paralysis. 

The condition of the fundus of the eye, as revealed by the 
ophthalmoscope, is of such importance that I shall consider 
it at some length. 

Bouchut a examined the fundus of the eye in all the gen- 
eral paralytics in the Salpetriere hospital, and found no evi- 
dent lesion which could account for the disease or for the 
inequality of the pupils. So far as I am aware, he was the 
first to apply the ophthalmoscope to the examination of the 
eyes in cases of general paralysis. The next statements on 

1 Zeitschrift fur Psychiatrie, H. 30, p. 570. 

2 " Du diagnostic des maladies du systeme nerveux par 1' ophthalmoscopic," 
Paris, 1866, p. 333. 



620 DESCRIPTION AND TREATMENT OF INSANITY. 

the point are those made by myself l in 1871, and which were 
based on the results obtained from many examinations during 
the six preceding years. These were that, in general paral- 
ysis, "atrophy of the optic nerve causes amaurosis or am- 
blyopia. Ophthalmoscopic examinations will generally detect 
this condition of the papilla at a very early stage of the dis- 
ease, together with retinal and choroidal anaemia. " 

In the same year Dr. Clifford Allbutt 2 published the re- 
sults of extensive observations with the ophthalmoscope in 
various nervous and mental diseases. He stated that, of fifty- 
three cases of general paralysis examined, changes in the 
optic nerve and retina were found in all but five. Of the re- 
maining forty-eight he found atrophy of the optic disk in 
various stages in forty-one cases, the other seven being doubt- 
ful. He concludes : 

"1. That atrophy of the optic nerves takes place in almost 
every case of general paralysis, and, I may add, of the olfac- 
tory nerves also. 

"2. That it does not travel down from the optic centers 
and along the tracts, but attacks the optic nerve as an inde- 
pendent tract of sclerosis. 

"3. It often becomes apparent as a hyperemia of the 
nerve with slight exudation, but without much stasis — as a 
'red softening,' in fact. It then whitens, generally from the 
outer edge inward, the nerve becoming white and staring, and 
its edge sharply defined." 

Dr. Aldridge, 3 after premising that patients with general 
paralysis are rarely if ever seen in asylums till they have 
passed the first stage, gives the results of the ophthalmoscopic 
examination of forty-three cases, in nearly all of which great 
vascularity of the disk or atrophy was observed in one or 
both eyes. The left eye was more frequently affected than the 
right, especially in the female patients. Thus, of thirteen 
women examined, the left optic disk was more atrophic than 
the right in ten, while in the other three these changes were 
equally advanced in both eyes. 

Growers, 4 on the contrary, asserts that most of the cases of 

1 a A Treatise on Diseases of the Nervous System," New York, 1871. 

3 "On the Use of the Ophthalmoscope in Diseases of the Nervous System 
and of the Kidneys," London and New York, 1871, p. 393. 

8 " Ophthalmoscopic Observations in General Paralysis," etc., West Riding 
Lunatic Asylum Medical JReports, vol. ii, 1872, p. 223, et seq. 

4 "A Manual and Atlas of Medical Ophthalmoscopy," London, 1879, p. 163. 



GENERAL PARALYSIS. 621 

general paralysis which he has examined in various stages of 
the disease presented perfectly normal conditions. In one 
case only did he find the appearance of simple congestion of 
the disk. 

Tebaldi, 1 of twenty cases of general paralysis, failed in 
one only to find abnormal ophthalmoscopic appearances. 
Klein 2 examined ophthalmoscopically forty-two general par- 
alytics. Of these, two gave negative results and six were 
doubtful. Of the remaining thirty-four, nine had various 
special conditions, such as dilatation of the veins and the ar- 
teries, choroiditis, attenuation of the veins and arteries, etc. ; 
five had retinitis ; two atrophy of the optic nerve and the 
disk ; one discoloration of the optic nerve ; one hyperemia 
of the nerve and disk ; and sixteen retinitis paralytica. 

Although ScMle 3 has very frequently remarked in the 
beginning of general paralysis an injected condition of the 
papilla with enlargement of the veins, he does not think that 
true atrophy of the optic nerve is an accompaniment of gen- 
eral paralysis. 

Voisin 4 has little to say of disturbances of sight in general 
paralysis till he comes to the consideration of the second stage. 
Then he states that the sight is notably weakened ; contours, 
colors, and objects become less distinct, and dyschromotop- 
sia exists. Sometimes one of the eyes loses more quickly 
than the other its visual power. 

Relative to the ophthalmoscope he says that it does not 
always explain the amblyopia. Of forty cases examined by 
him, in conjunction with Galezowski, in two only a partial 
atrophy was found ; in two there was dilatation of the cen- 
tral artery of the retina ; but in a large number of cases flexu- 
osities and a congested condition of the arteries of the retina 
were met with— conditions which, as he declares, are to be 
accounted for by what we know to exist in the vessels of the 
meninges in general paralysis. 

I have data of the ophthalmoscopic examination of forty- 
two general paralytics in the prodromatic stage, and of thirty- 
one after the disease was well established. Of these latter, 

1 "L'ottalmoscopia nelle alienazione mentale,' 1 Bologna, 1870. 

2 " Augenspielstudien bei Geisteskranken. Leisderdorf s psychiatrische Stu- 
dies," Wien, 1877, p. 113. 

3 Cited by Mendel, u Die progressive Paralyse der Irren," Berlin, 1880, p. 141. 

4 u TraitS de la paralysie generale des alienes, 1 ' Paris, 1879, p. 111. 



022 DESCRIPTION AND TREATMENT OF INSANITY. 

seventeen belonged also to the prodromatic category, making 
fifty-six different patients. Of the forty-two exhibiting well- 
marked prodromatic symptoms, such as I have described in 
the beginning of this section, twenty-nine exhibited anaemia 
of the fundus. The arteries and veins were thin and straight, 
and the choroid was paler than in the normal condition. These 
appearances were almost invariably found in both eyes to the 
like extent. In four, the fundus appeared to be healthy, 
and in nine the vessels were enlarged and tortuous, and the 
disk was in a hypersemic state. 

Of the thirty-one other cases, twenty-one were examined 
while the patients were still in what is called the first stage. 
Of these, incipient atrophy, beginning on one edge of the disk, 
existed in seventeen ; in one there was choked disk ; in two 
hyperemia of the disk, with enlarged and tortuous vessels ; 
and in one the fundus appeared to be normal. Eleven of 
these patients had been examined by me while they were in 
the prodromatic stage at anterior periods, ranging from two 
to ten months. All of them had atrophy of the disk. 

The ten remaining patients were examined during the 
middle and closing periods of the disease, and all had atrophy 
of the optic nerves of both sides, though not to the same 
extent on each. Six of these patients I had examined at 
former periods. 

The hearing I have found in some cases, during the early 
periods of the disease, to be decidedly intensified. This was 
notably the case in a general paralytic whom I examined in 
the City Prison some three years ago, who was discharged by 
the verdict of a jury from the custody of his relatives, on the 
ground that he was sane, and who is now in a lunatic asylum 
in Pennsylvania if he be not dead. l 

Later, in some few cases, the hearing is markedly impaired, 
but in the majority of instances it is not perceived to be per- 
ceptibly lessened in intensity. 

The taste, as might be expected in those patients who have 
suffered from diminution or loss of the sense of smell, is im- 
paired in acuteness very generally. General paralytics, as 
Yoisin remarks, eat with indifference everything that is put 
before them. 

1 " Remarks on General Paralysis, with Special Reference to the Case of 
Abraham Gosling," before the New York Medico-Legal Society, Medical Ga- 
zette, May 8, 1880. 



GENERAL PARALYSIS. 623 

Nutrition is not usually affected to any considerable 
extent during the early stages of general paralysis, but as 
the disease advances various derangements of the normal 
standard make their appearance. Sometimes, however, ema- 
ciation begins from the very inception of the disease. Later, 
atrophy of an active character may ensue in one or more of 
the limbs, and this is especially apt to be the case when the 
spinal cord is involved in the morbid process. 

Bed-sores are often a painful and troublesome feature of 
the disease. They appear by preference on those parts which 
are subjected to pressure, in sitting or lying, such as the but- 
tocks, the sacral region, the heels, the elbows, or the shoul- 
ders, though they are not always confined to these parts. 
When numerous or extensive, they cause a good deal of con- 
stitutional disturbance. The theory advanced by Charcot 
and his pupils, that the situation of the bed-sore is in anatom- 
ical relation with the nerve-centre which is the seat of the 
lesion, does not appear to hold good for general paralysis. 

Hematoma auris, a condition which has already been 
described under the head of acute mania, is a not uncommon 
occurrence in general paralytics. Its appearance is said to 
be unfavorable from a prognostic point of view, but it is diffi- 
cult to see how any event can add to the gloomy prognosis 
of so nearly uniformly, a mortal disease as is general paralysis. 

Fractures of the ribs and other bones are met with in gen- 
eral paralytics in asylum practice, and appear to be due to 
slight violence acting on bones which are in an abnormal 
state as regards nutrition. As the subject has already been 
sufficiently considered under the head of acute mania, it does 
not at present require further amplification. 

The normal temperature of the body is subject to con- 
siderable variations during the course of general paralysis. 
Clouston ' found it higher in the mean in patients with this 
disease than in any other form of insanity, and that the aver- 
age evening temperature was always higher than the average 
morning temperature. He also found the temperature to be 
high in the first stage, low in the second, and highest in the 
third or last stage. These results were in the main confirmed 
by Mickle, 1 who has investigated the subject with great 

1 Journal of Mental Science, April, 1868. 

2 Journal of Mental Science, April, 1872 ; also " General Paralysis of the In- 
sane," London, 1880, p. 43. 



624 DESCRIPTION AND TREATMENT OF INSANITY. 

thoroughness, and ascertained several additional points. By- 
means of Lombard's thermo- electrical apparatus, I have been 
able to establish the fact that after the disease has fairly en- 
tered upon the first stage, there is a decided elevation of the 
temperature of the head, amounting in some cases to as much 
as two degrees Fahr., and that the point of highest tempera- 
ture is at the vertex. 

Among other phenomena are those which relate to the 
pulse and the bladder, and other organs, the derangements 
of which do not require further consideration in a work de- 
voted to the whole subject of insanity. As regards the pulse, 
Dr. George Thompson, 1 in an interesting memoir, shows that 
in general paralysis, the normal pulse-tracing, as obtained by 
the sphygmograph, is altered, so that the line of ascent be- 
comes slanting and short, while that of descent is gradual 
and prolonged, and does not display the usual aortic notch, 
but instead presents a number of wavelets, which, if counted 
carefully, will be found to vary from six to ten in number. 
He ascribes this phenomenon to a persistent spasm of the ves- 
sels which exists as one of the earliest symptoms. 

In the accompanying tracings, made by means of Pond's 
sphygmograph, from the same patient at different stages of 
the disease, the variation in the action of the heart and arter- 
ies is very distinctly shown. 

The patient, a gentleman of forty-five years of age, was 
brought to me, July 20, 1882. He was then, I thought, and as 
the result showed, in the prodromatic stage of general paral- 
ysis. There was a slight degree of mental depression with ex- 
citement, inequality of pupils, and slight derangement of the 
articulation. These symptoms had been present for about two 
months. 

The first tracing, No. 1, made July 20th, indicates vaso- 
motor paralysis, and feebleness of the heart's action. There 
is no aortic notch. No. 2 was made September 3d, and is 
almost the opposite of No. 1 in all respects. It shows vaso- 
motor spasm, and exhibits the wavelets, in numbers of from 
six to seven or eight, on each line of descent. The aortic 
notch is absent. The patient was at this time in a state of 
extreme d'elire de grandeur. He thought he had been com- 
missioned by the President to build railroads in Mexico. He 

^'The Sphygmograph in Lunatic Asylum Practice," West Riding Lunatic 
Aaylum Medical Reports, vol. i, p. 58. 



GENERAL PARALYSIS. 



625 



intended to make a " railroad gridiron" of that country ; was 
going to buy np all the iron-fnrnaees in the country, and put 
them to work making rails ; had bought, he said, over two 
hundred thousand engines and a million cars. Then he was 
going to tunnel all the mountains in Mexico, in search of 
gold and silver ; and so on, with a dozen or more delusions, 
during the hour that I saw him. 



2 
3 

4 
5 
6 
7 



Fig. 7. 




Xos. 3 and 4 were taken on September 29th and 30th, re- 
spectively. They show feebleness of the heart and increased 
arterial tension. The line of ascent is slanting; the line of 
descent has no aortic notch, and the number of wavelets 
reaches ten or more. Has delusions of immense wealth, and 
of high official position ; owns all the brass - works in the 
world, and is governor of the Russo-Americo- Japano-Chinese 
Alliance for the buying of all the tea in the world. 

Nos. 5, 6, and 7 were taken November 2d, 5th, and 10th, 
respectively. The patient was then in a state of dementia, 
was scarcely able to walk ; had had two epileptic paroxysms 
since I last saw him, which was October 30th. These tracings 
show great cardiac and arterial debility, but the last two 
are better than the first. From that time on there was a de- 
cided improvement in the mental and physical symptoms, and 
a remission lasting till the early part of January ensued. He 
is now, however, in a relapsed condition, with mild delusions 
of greatness and marked ataxic symptoms. 

The bladder is generally involved at some time or other in 
the course of general paralysis, and this is especially though 
not entirely noticeable in those cases characterized by the ex- 

40 



626 DESCRIPTION AND TREATMENT OF INSANITY. 

istence of ataxic symptoms. There may either be spasm or 
paralysis of the sphincter, producing ischuria or inconti- 
nence, or the bladder itself may be the seat of paralysis, in 
which case the urine dribbles instead of being passed with 
force and in a full stream ; or the sphincter and bladder may 
both be paralyzed, leading to involuntary dribbling. Again, 
in consequence of the paralysis of the bladder, the urine, re-- 
maining too long a period in the organ, sets up cystitis of an 
acute or chronic form, which may complicate very unfavor- 
ably the condition of the patient, and shorten the duration of 
the disease. 

It is a notable characteristic of general paralysis that 
remissions in its intensity generally occur, during which the 
symptoms physical and mental abate in violence, and the 
patient's friends imagine that he is certainly recovering. In- 
deed, the phenomena may disappear to such an extent as not 
to be evident to general observers, or even to those who are 
brought into daily contact with the patient, unless they are fa- 
miliar with certain characteristics of the disease not obvious to 
non-medical persons. I have now under my care a gentleman 
from the interior of this State, who has already passed several 
months in a lunatic asylum, on account of general paralysis. 
He has been out of the asylum about four months, and a 
month since I allowed him to resume his business, that of a 
merchant. When he first came to me, he had pain in his 
head, deranged articulation, trembling of the lips and tongue, 
inequality of the pupils, and a slightly titubating gait. 
There was no mental derangement, except a tendency to men- 
tal depression, and to shed tears upon slight occasion. After 
three months, every symptom, mental and physical, had dis- 
appeared, except the inequality of the pupils. He was cheer- 
ful, talked well, had no tremor, was strong and apparently 
healthy in every respect. When he had been back at his 
business for about a month, I saw him again. In the mean 
time he had done a great deal of work, and had travelled sev- 
eral thousand miles West and South, in the performance of his 
mercantile duties. There were still no symptoms that I could 
discern, except the inequality of the pupil. Even the hyper- 
semic condition of the optic disks had disappeared. I may 
mention incidentally that he was treated mainly with mer- 
cury, large doses of iodide of potassium, and counter-irritation 
to the vertex. Doubtless, if he were less prudent, accessions 



GENERAL PARALYSIS. 62 T 

of mental disturbance would occur, but lie is careful to avoid 
fatigue, excitement, and the use of alcoholic liquors ; yet, 
notwithstanding all his care, the probability is that eventually 
his remission will come to an end. 

In his original description of the disease, Calmeil ' called 
attention to this peculiarity of general paralysis ; and it has 
been subsequently, at different times, studied by Baillarger, a 
Sauze, 3 Doutrebente, 4 and others. 

Sauze recognized three different kinds of remissions. In 
the first the somatic symptoms disappear, while the mental re- 
main ; in the second, the mind appears to return to its normal 
condition, while the somatic symptoms persist ; and, in the 
third, the mental and physical symptoms are greatly ameli- 
orated, but do not entirely disappear. There is never, there- 
fore, according to him, a distinct, absolute remission of all 
the symptoms. 

Doutrebente makes two classes of remissions, the incom- 
plete and the complete, and each of them is divided into two 
kinds, the temporary and the durable. 

The temporary incomplete remissions are the most fre- 
quent of all. Their duration is short, but variable, as is also 
their intensity. They are often reproduced a great many 
times in the same patient. In a case which I had before my 
class at the Post-Graduate Medical School, in February 14, 
1883, a cursory examination revealed the existence of in- 
equality of the pupils, tremor of the lips and tongue, defective 
articulation, and an exalted mental condition. As the hour 
had expired, I sent him away to return on the 21st, when I 
proposed to make him the subject of a clinical lecture. At that 
time, however, his pupils were equal, there was no tremor, 
his articulation was good, and his mind calm and equable, 
without the least sign of exhilaration. On the 24th, however, 
all the symptoms first observed had returned ; and, so far as 
the mind was concerned, to an increased degree. 

Incomplete durable remissions are not limited as to dura- 
tion. They have been known, it is said, to last for ten, fif- 
teen, or even twenty -five years, but one or more of the phe- 

1 "De la paralysie g6n6rale," Paris, 1826. 

2 Union Medicate, 1855 ; Annates medico-psychotogiques, 1847, p. 335 ; and 
Hid., 1876 and 1879. 

3 Annates medico-psychotogiques, 1858. 

4 Annates medico-psychotogiques, mars-mai, 1878. 



628 DESCRIPTION AND TREATMENT OF INSANITY. 

nomena persist, and the patients are generally subject to 
repeated congestive attacks, or epileptiform seizures. 

Temporary complete remissions are more common in the 
beginning of general paralysis than at other periods. They 
are true intermissions of short duration, during which all the 
symptoms disappear. In my opinion, however, they are not 
instances of the entire disappearance of all the symptoms. 
It is true the symptoms almost vanish ; delusions are no 
longer held, and the physical symptoms are so far mitigated 
as scarcely to be noticeable, but that is the most that can be 
said. Something — as the inequality of the pupils in the case 
detailed — remains, and soon the fire is in full blaze again. 

A complete durable remission is in reality a cure. Many 
of these have been reported, and by authorities that cannot 
be questioned, and are cited in full by Doutrebente. Thus 
Billod reports a case in which there was an entire cessation 
of all the symptoms, and at the end of eight years they were 
still absent ; Lunier, one in which, after thirteen years, there 
was still complete absence of all symptoms ; Morel, one in 
which, after the disease had lasted eight months, it disap- 
peared with the discharge of a large abcess of the liver, and 
three years afterward the patient was following his trade of 
a dyer in Paris without any derangement of his mind or 
body ; Delasiauve, one in which, after fifteen months' dura- 
tion of the disease, it was cured, and eight years subsequently 
the patient was still in good health. 

These are only a few of the cases adduced by Doutrebente, 
who also cites several which occurred in his own experience. 
I have never had the good fortune to witness a single case of 
the kind ; neither have I noticed one in which there was a 
complete disappearance of every symptom of the disease. 

On this subject my opinion is in accordance with that of 
Baillarger and Luys, 1 which is that remissions are almost al- 
ways the result of the disappearance of the acute maniacal 
or melancholic attacks which result from superadded conges- 
tion or anaemic conditions, and that the original substratum 
of the disease remains to produce its legitimate symptoms. 
If the focus or cortical lesion is small, the phenomena are 
restricted ; if it is large, they are more extensive. 

Convulsive seizures have already been mentioned as occur- 
ring during the course of general paralysis. They are some- 

1 Annales medico-psychologiques, juillet, 1877, pp. 110, 111. 



GENERAL PARALYSIS. 629 

times characteristic features of the disease. Usually they are 
epileptiform, though occasionally they are of the nature of 
apoplexy. They vary greatly in character, sometimes con- 
sisting of attacks of petit mal, while at others they consist of 
strong convulsive seizures, not differing essentially from the 
grand mal of epilepsy. Yoisin ' cites several cases occurring 
in women in which the convulsive seizures were of the char- 
acter of hystero-epilepsy. Accessions of coma are also met 
with. All these complications are doubtless due to sudden 
augmentations of the existing congestive state of the brain. 
Tetanic spasms have also been observed. 

The duration of general paralysis is variable. Sometimes 
death results in a few months, and at others it may be de- 
ferred for five or six years. The average period is about three 
years. 

As has already been intimated, general paralysis is almost 
invariably fatal. The cases of cure that have been reported, 
though amounting to perhaps a hundred all told, are scarcely 
to be considered when compared with the large number of 
cases that have gone on steadily to a fatal termination. Br. 
Allbutt made his ophthalmoscopic examinations in general 
paralysis on fifty- one patients in the West Biding Lunatic 
Asylum. Four years afterward, when Dr. Aldridge came to 
make similar observations, not one of Dr. Allbutt's cases was 
alive. 5 About twenty per cent, of all the deaths occurring in 
lunatic asylums are from general paresis. Death may take 
place from a convulsive seizure, or during the coma resulting 
from congestion, from sheer exhaustion, from the gradual 
cessation of the respiratory process, or from the supervention 
of some intercurrent affection. But, before that event occurs, 
the patient, unless suddenly carried off by one of the causes 
referred to, passes with more or less rapidity into the stage of 
absolute mental and physical prostration. Bed-sores become 
a prominent feature, his urine and faeces are passed involun- 
tarily, he is an extreme instance of the u wet and dirty" con- 
dition, which, perhaps, has existed with more or less intensity 
from an early period, but which now is his permanent state. 
Unable to speak, he mutters unintelligibly. But, if a word 
can be gathered here and there, it shows that he is still the 
victim of delusions, and often of those grand ideas of his 

1 Op. tit., p. 221. 

9 West Riding Lunatic Asylum ^Medical Reports, vol. ii, 1872, p. 225. 



630 DESCRIPTION AND TREATMENT OF INSANITY. 

strength and importance, his wealth and knowledge, which 
have played so striking a part in the clinical history of his dis- 
ease. His life is almost reduced to the vegetative condition, 
so far, at least, as his relations with the external world are 
concerned. Swallowing is impossible, respiration is labored, 
the heart beats irregularly and feebly, and, when death comes, 
its approach is so gentle that those around scarcely notice 
that the patient is a corpse. 



CHAPTER VIII. 

VI. 

CONSTITUTIONAL INSANITIES. 

By constitutional insanities I do not intend to include 
those forms of mental derangement which simply owe their 
existence to a morbific influence acting as a cause only, and 
not giving a peculiar phase of its own to the aberration of 
mind. Thus, there is an insanity caused by malaria, another 
by alcohol, another by syphilis, another by gout, and so on 
for a dozen or more others. But I do refer to the insanities 
which are intimately related — not only etiologically but path- 
ologically — with certain physical conditions which impress 
upon the mental disease something that makes it different 
from other insanities. To the most important of these the 
attention of the reader is requested. 

a — EPILEPTIC INSANITY. 

There is more or less mental derangement with every epi- 
leptic paroxysm, but there is a form of the seizure to which 
the term epileptic insanity or epileptic mania is especially 
applicable. 

The relations of epilepsy to insanity were imperfectly 
known to medical writers of a hundred or more years ago, but 
they were first clearly formulated by Renaudin, 1 who showed 
that a paroxysm of insanity, temporary in duration, some- 
times replaced the true epileptic seizure, or, if not altogether 
substituted for it, was violent in proportion to the feebleness 
of the usual attack. 

1 Annales medico-psychologiques, 1850, t. ii, p. 479. 



EPILEPTIC INSANITY. 631 

Billod ' regarded the maniacal and the ordinary epileptic 
paroxysm as two forms of one disease, and Falret 8 arrived at 
the conclusion that the paroxysms of insanity and of epi- 
lepsy occurring in an epileptic are only different manifesta- 
tions of the same pathological condition, which can exist 
separately or together, or follow each other at longer or 
shorter intervals. 

Morel* went still further, and showed that there was a 
form of insanity characterized by some of the most striking 
psychical manifestations of epilepsy, but in which there never 
had been any known association with true epileptic parox- 
ysms. For a long time he had remarked that there was a 
certain class of patients in whom accessions of acute mania 
occurred with great suddenness, and then as suddenly disap- 
peared. At first he had thought these cured, but the recur- 
rence of the attacks, at more or less regular intervals, convinced 
him of his error. There were no prodromata other than an 
increased degree of activity and mental excitability, and they 
went on with their ordinary occupations up to the last mo- 
ment. Then like a thunder-clap the seizure came, and in 
exactly the same form as previous attacks. Violence, ex- 
treme delirium, a tendency to the perpetration of acts of de- 
struction or injury, irresistible impulsions, and then the sub- 
sidence of all the phenomena, and a return to the ordinary 
state of health. To this affection he gave the name of epi~ 
lepsie larvee — concealed or masked epilepsy. 

Since then Falret, Delasiauve, Legrand du Saulle, Spitzka, 
and many others have studied the subject in all its relations 
to medical and legal science. There are probably yet, not- 
withstanding all the labor which has been bestowed upon it, 
many points in its clinical history which have not been eluci- 
dated. 

The ordinary form of an attack of epileptic insanity is 
characterized by a suddenness which has not its equal in the 
whole range of psychological medicine, and it is very often 
the case that an act of extreme violence marks the culmina- 
tion of the paroxysm. The seizure then usually but not al- 
ways ceases, and, after a short period of more or less mental 
disturbance, the patient regains his ordinary mental and phys- 

1 Annates medico-psychologiques, 1850, t. ii, p. 611. 

2 "Archives generates de medecine," t. xvi, 1860, p. 661. 
8 "Traite des maladies mentales," Paris, 1860, p. 480. 



632 DESCRIPTION AND TREATMENT OF INSANITY. 

ical condition ; sometimes the attack is prolonged through 
several hours, or even days. 

The approach of the paroxysm may be indicated to the 
patient by sensations in various parts of his body, generally 
in the region of the solar plexus, or in the head, the former 
consisting of an anxious feeling, or such as is produced by 
hunger, and the latter ordinarily of vertigo. In the majority 
of cases there are no warnings or aurae. 

The citation of a few cases, from the writings of others, 
and from my own experience, will tend to the elucidation of 
the symptomatology. Many of the instances that have been 
reported under the heads of morbid impulse, homicidal 
mania, mania transitoria, etc. , are cases of epileptic insanity. 

Legrand du Saulle 1 reports the following cases : 

A young man of good intelligence, and belonging to a 
family of high rank, had at his command all the luxuries of 
life. Three or four times a year he experienced a particular 
sensation in the stomach, always of the same character, and 
in a few seconds afterward was overcome by a feeling which 
he could not describe, and he no longer possessed the con- 
sciousness of his acts. When he recovered his lucidity, at the 
end of a period lasting several hours, and sometimes one, two, 
or three days, he was surprised to find himself greatly fa- 
tigued, far from his home, on a railway or in a prison, his 
clothing in disorder, and himself without any recollection of 
what had passed. In his pockets there would be porte-mon- 
naies, jewelry, cigar-cases, knives, laces, bank-notes, gold 
pieces, letters, medals, and many other articles. He had no 
idea how these things came into his possession, but would 
add that he must have had a paroxysm of his disease. 

In May, 1867, Philibert V , aged twenty-one, assassi- 
nated, at the corner of the Rue Princesse, at five o' clock in the 
morning, a peaceable old man, whom he had never seen be- 
fore. He was arrested with the bloody knife with which he 
had done the deed in his possession. The fact of his insanity 
being recognized, he was sent to the Bicetre, where he came 
under M. Legrand du Saulle's observation. 

At first sight the young man appeared to be good-tem- 
pered, reasonable, and incapable of a criminal act. He knew 
nothing of what had happened, was surprised at being in ar- 
rest, and demanded to be sent back to his home. His mother 

1 " Etude medico-legale sur les epileptiques," Paris, 1877. 



EPILEPTIC IKSAfflTY. 633 

declared that lie liad never been affected with any serious dis- 
ease, that he always behaved himself well, that he was sober, 
a good worker, bnt that from time to time he was singular, 
irritable, threatening, and that he had intentionally given 
himself several blows on the head. Then he would go out 
agitated, and return quite worn out at the end of twenty-four, 
thirty-six, or forty-eight hours ; and that, with the most honest 
purpose possible, he could not tell where he had been, or what 
he had done, or where he had slept, or what he had eaten. 
Then he went to work, and was as well as though nothing had 
happened. 

The evening before the crime, Philibert had passed the 
whole day at the Exposition, and had brought back with him 
some Protestant books, which he had read during the night, 
notwithstanding the entreaties of his mother, who had begged 
him to take some rest. He had arisen in the morning very 
much excited, dressed himself hurriedly ; had abused his 
mother, possessed himself of a kitchen-knife, and had gone 
out in a furious state of mind. He was in this mental condi- 
tion when he killed the first person he met. 

M. Legrand du Saulle was convinced of the reality of his 
amnesic state. He called to mind the fact that the ordinary 
lunatic recollects the criminal act he may have committed, 
while the epileptic, on the contrary, does not, or does so very 
imperfectly. He did not, therefore, hesitate to give an opin- 
ion that the young man had committed the crime during a 
paroxysm of epilepsy. 

Marc ' relates the following instances : 

A shoemaker, aged thirty -five, an industrious and sober 
man, rose early one morning and resumed his work. Shortly 
afterward his wife noticed that his speech was irrational and 
incoherent, and suddenly the unfortunate man seized his 
knife and rushed furiously upon her in order to kill her. 
His face was red, and his whole aspect was that of a maniac ; 
gradually he became quiet, but his pulse was full and fre- 
quent, his tongue dry, and the surface of his body covered 
with perspiration. In a few hours he was calm and asleep, 
and in the evening was perfectly rational. He had no recol- 
lection whatever of the events of the morning. 

A Swabian peasant, who had for eighteen years been sub- 

1 "De la folie consideree dans ses rapports avec les questions judiciaires,"' 
Paris, t. ii, p. 510. 



G3i DESCRIPTION AND TREATMENT OF INSANITY. 

ject to epileptic paroxysms, experienced a change in the type 
of his disease, the fits being replaced by attacks of homicidal 
fury. The impulses to kill were preceded by somnolence and 
lassitude. When he felt them coming on, he would beg to 
be restrained, and would implore his mother and others to 
get Out of his way. He had no subsequent recollection of his 
acts. 

The following cases occurred in my own experience : 

J. H. consulted me for epilepsy in the summer of 1869. 
His ordinary attacks were of the fully-developed form, but 
upon two occasions they were different from any with which 
he had previously been affected. In one of these, while over- 
looking some workmen, he was observed to put his hand to 
his head, and then suddenly to run toward a fence which he 
speedily climbed. Jumping down into the back-yard of an 
adjoining house, he seized a stick of wood near by, and made 
a furious onslaught on the doors and windows. He was, 
however, seized by several men, and forcibly held, notwith- 
standing his struggles. While thus being restrained, he re- 
covered his consciousness, but had no recollection of anything 
that had taken place after he had put his hand to his head, 
which action, he said, was due to severe pain and vertigo. 
The duration of the attack was not over three minutes. 

On the other occasion, he was seized with pain and vertigo 
which engaged in paying a bill at a coal-yard. He rushed 
into the street and began to turn rapidly round. He was 
seized and held till he recovered his consciousness. This at- 
tack lasted about four minutes. 

Subsequently he had a similar paroxysm in my consult- 
ing-room. His face became very pale, his eyes were fixed, 
and his pupils oscillated. Suddenly he rose from the chair, 
grasped the mantel-piece for an instant, and then rushed vio- 
lently around the room, throwing his arms about and utter- 
ing a peculiar inarticulate cry. I made no attempt to re- 
strain him, and in about two minutes he became calm. Dur- 
ing the whole paroxysm his face was pale, and at its close 
the pupils were dilated. He had no recollection of anything 
that had occurred after he rose from the chair, but was con- 
scious then of vertigo. 

Another case is that of a girl brought to my clinique at 
the Bellevue Hospital Medical College during the summer of 
1869. She had been severely injured in the skull by a fall 



EPILEPTIC INSANITY. 635 

against a mass of old scrap-iron. Necrosis subsequently en- 
sued, and several large pieces of the external table were ex- 
foliated. While before the class she started to her feet and 
walked several times around the enclosed area. She was un- 
conscious, and to all appearance insensible. When the par- 
oxysm was over, she returned to her seat. The duration did 
not exceed a minute, and there was no excitement or delirium. 1 

In this case there were no acts of violence, though there 
were probably hallucinations or illusions, for the girl went 
up to two or three of the gentlemen sitting on the front row 
of benches, and mumbled out some words to them, and it is 
possible there were delusions which influenced her conduct. 
In the two following cases there is still greater reason for 
supposing that the conduct of the patients was the result of 
erroneous mental conceptions. 

A partner in an extensive mercantile establishment, who 
was subject to attacks of both the grand and the petit mat, 
left his oflice at about eleven o'clock for the purpose of getting 
a signature to a paper of some kind from a gentleman whose 
place of business was a few minutes' walk distant. Not re- 
turning by three o' clock, inquiry was made, and it was ascer- 
tained that he had visited the office, obtained the signature, 
and had left in apparently good health before half -past eleven. 
Since then nothing had been heard of him. He did not make 
his appearance at his own oflice till nearly five o'clock. 

The last thing he recollected was passing St. Paul's Church, 
at the corner of Broadway and Yesey Street, just as the con- 
gregation was coming out after morning service. It was sub- 
sequently ascertained that he had gone to Brooklyn after 
getting the signature he wanted ; had visited a newspaper 
oflice, and purchased a paper ; had returned to New York, 
entered an omnibus at the Fulton Ferry, left it at the corner 
of Twenty-third Street and Fifth Avenue, entered the Fifth 
Avenue Hotel, and while there recovered his recollection. 

But none of these cases, nor any of which I have seen the 
report, are equal in interest to one which occurred in my 
practice during the autumn of 1875. The patient, who was 
engaged in active business as a manufacturer, left his oflice 
at about 9 a. m., saying he was going to a florist's to purchase 
some bulbs. He remained absent eight days. He was tracked 

1 " A Treatise on the Diseases of the Nervous System," New York, seventh 
edition, p. 693. 



G36 DESCRIPTION AND TREATMENT OF INSANITY. 

all over the city, but the detectives and friends were always 
an hour or more behind him. It was ascertained that he had 
been to theatres ; to hotels, where he slept ; to shops, where 
he had made purchases ; and that he had taken a journey of a 
hundred miles from New York, and losing his ticket, and not 
being able to give a satisfactory account of himself, was put 
off of the train at a way-station. He had then returned to 
New York, passed the night at a hotel, and on the eighth 
day, at about ten o' clock, made his appearance at his office. 
He had no recollection of any one event which had taken 
place after leaving his office eight days previously, till he 
awoke on the morning after his return to the city, and found 
himself at a hotel at which he was a stranger. It was ascer- 
tained beyond question that in all this time his actions had 
been entirely correct, to all appearance ; that his speech was 
coherent, and that he had acted in all respects as any man in 
the full possession of his faculties would have acted. He had 
drunk nothing but a glass of ale, which he took with some 
oysters at a restaurant in Sixth Avenue. 

It could not be ascertained that this patient had ever had 
an epileptic paroxysm ; but he had a year previously been 
under my charge for cerebral symptoms, indicating the ex- 
istence of chronic basilar meningitis, and, only a week before 
his disappearance, I had discharged him cured after a month's 
treatment for severe pain in the head, vertigo, paralysis of 
the third nerve on the right side, and extreme insomnia. 
These were all indications of a specific cause, and I had 
treated him with large doses of the iodide of potassium, as 
on the former occasion. 1 

The following case, though differing in the most striking 
manifestations from the last two cited, is yet essentially the 
same in character. 

I was consulted in the case of a young lady, an inmate of 
a fashionable school in this city, who, immediately before 
each menstrual period, was attacked with paroxysms of great 
and uncontrollable excitement, during which she attempted 
to destroy everything within her reach. In one of these, 
which had occurred just before I saw her, she had broken a 
large drawing-room mirror, a mantel- clock, and several valua- 
ble vases and ornaments, before she could be restrained. One 
morning she entered my consulting-room with her governess, 

1 Op. cit., p. 694. 



EPILEPTIC INSANITY. 637 

and, almost before I could speak to her, the fit seized her. 
Her face and neck became red, her eyes sparkled, she trembled 
from head to foot, and, ere I was able to prevent her, she 
seized a bronze, dagger-like paper-knife that lay on the table, 
and attempted to plnnge it into her breast. Fortunately, it 
struck against the steel support of her corsets, and, before she 
could repeat the act, I caught her arm and took the weapon 
from her. In a few moments she was calm, and had no recol- 
lection of what she had done. The attack was clearly one of 
epileptic mania, and shortly afterward her seizures assumed 
the regular form of the grand mat. 

A young man residing in Boston, and who was under my 
charge for epilepsy, of which he had attacks of both the 
grand and petit mal several times in the course of each 
month, one evening while eating supper with his mother, 
rose suddenly from the table, his face bearing a wild expres- 
sion, and, rushing up-stairs to his bedroom, took a razor and 
drew it across his throat, before those who followed him could 
prevent the act. For several hours afterward he was in a 
state of exalted delirium. When this passed off, he had no 
recollection of anything that had occurred since he had sat 
down at the supper-table. A good portion of the meal, 
therefore, must have been eaten during the paroxysm, which 
in the beginning was of a quiet character. 

The foregoing cases are sufficient to show the general char- 
acteristics of a paroxysm of epileptic insanity. It will be 
seen that there is not always a tendency to violence. During 
the seizure, it sometimes is very evident that the patient suf- 
fers from false sensorial impressions, for he utters words which 
show what is passing through his mind. Indeed, as is well 
known, the ordinary epileptic paroxysm is occasionally pre- 
ceded by hallucination, and I have recently published a mem- 
oir on a form of epilepsy, in which hallucinations and uncon- 
sciousness are the only manifestations. 1 It would be a slight 
transition from this variety to that under consideration. The 
case, the particulars of which are given on page 318, is also an 
instance of the facility with which hallucinations can be pro- 
duced in epilepsy. Moreover, there are certain cases in which 
the recollection of what has occurred during the seizure is not 

1 " On Thalamic Epilepsy," Archives of Scientific Medicine, August, 1880 ; 
also " A Treatise ou Diseases of the Nervous System," seventh edition, New 
York, 1881, p. 695. 



G3S DESCRIPTION AND TREATMENT OF INSANITY. 

altogether lost, and in which, therefore, the patient is able to 
speak of the illusions or hallucinations that have occurred to 
him. Again, before losing consciousness, and passing into 
the paroxysm, he may have deranged sensorial perceptions, 
which he recollects very well, and which he can describe 
after the seizure has passed off. Many cases of either cate- 
gory are on record. The following occurred in my own ex- 
perience : 

A man, aged thirty-five, was subject to epileptic par- 
oxysms, which were occasionally replaced by attacks of vio- 
lent delirium, characterized by mental and physical agita- 
tion, and by efforts on his part to bite, scratch, strike, and 
kick those about him. He never inflicted any severe injury, 
and, having acted in the manner stated to those about him, 
would resume his walking, gesticulating, and speaking. His 
language showed that he thought the persons in the room 
with him were making fun of him, and ridiculing him by 
pointing their fingers at him, and calling him offensive names. 
The paroxysm lasted only a few minutes, and when it was 
over he had a distinct recollection of all that had occurred 
in connection with the illusions, but of nothing else. 

In another case the seizure was always preceded by the ap- 
pearance of red figures of various kinds — goats, sheep, oxen, 
horses, lions, tigers, and many others — which seemed to be 
running, skipping, and jumping before him. This continued 
for two or three minutes, and then the explosion took place, 
either into an epileptic paroxysm of the ordinary convulsive 
kind, or into an accession of epileptic insanity, in which there 
were all the phenomena of an attack of acute mania with 
tendency to acts of violence, concentrated into the space of 
less than ten minutes. In this case, only the hallucinations 
which occurred before the full development of the seizure 
were recollected, but the cries and actions of the patient dur- 
ing the continuance of the paroxysm left no room for doubt 
that there was intense sensorial aberration throughout the 
attack. 

All these cases are of the kind to which Morel, as we have 
seen, applied the term " masked epilepsy " (epilepsie larvee). 
They take the place of the ordinary attacks. But there are 
others in which the paroxysm of insanity precedes, and others 
again in which it follows the epileptic seizure. All these vari- 
eties are especially interesting in their medico-legal relations, 



EPILEPTIC INSANITY. 639 

and have been very thoroughly studied from that stand-point 
by Lunier, 1 Kraft-Ebing, 3 and others. 

Maniacal paroxysms occurring immediately before an epi- 
leptic attack are very rare ; and are probably not instances of 
epileptic mania, but of mania with epilepsy ; those following 
a seizure are common, and, according to Dr. Hughlings Jack- 
son, 8 are the only forms of transitory mania accompanying 
epilepsy, or resulting from the existence of the epileptic pre- 
disposition in an individual. In this view, he is not, I think, 
supported by facts. 

In cases of epileptic mania such as I have cited, there is 
in one sense a loss of consciousness, but in another sense the 
consciousness remains. There is a loss of the knowledge of 
the relations of the individual to the world and of his own 
identity, but he is conscious at the time of all that occurs dur- 
ing his paroxysms, although when this is over he has no rec- 
ollection of his former state of consciousness. There are, in 
fact, two states of consciousness, in neither of which has he 
any recollection of the other. Several cases of prolonged 
states of double consciousness have been reported. In these 
the individuals led separate and distinct lives, knew different 
people, had different habits, and were possessed of different 
mental characteristics in each state. In each of the periods 
the individual was conscious, but he had no recollection in 
one state of consciousness of any circumstance which took 
place in the other.* 

Epilepsy produces in many cases deterioration of the men- 
tal faculties and consequent dementia. In some instances this 
is only a temporary state of mental weakness, due to exhaus- 
tion of the brain by frequent discharges of nerve-force. It is, 
therefore, easily recovered from if the paroxysms are stopped. 
The other is secondary or terminal dementia, the result of or- 
ganic lesion or want of cerebral development, and is incurable. 

1 " Zweifelhafte Geisteszustande vor Gericht," Berlin, 1869. 

2 " Die Lehre von der Mania transitoria," Stuttgart, 1865, and " Lehrbuch der 
gerichtlichen Psychopath ologie," Stuttgart, 1875. 

8 " On Temporary Mental Disorders after Epileptic Paroxysms," West Biding 
Lunatic Asylum Hospital Medical Reports, vol. v, 1875, p. 105. 

4 See " Amnesie periodique, ou dedoublement de la vie," par M. Aznam, 
Annales medico-psychologiques, July, 1876 ; and paper by Dr. Mesnet, in V Union 
medicale, July 21 and 23, 1874, translated in the Chicago Journal of Nervous 
and Mental Disease, August, 1880 ; also, Neurological Contributions, No. 3, New 
York, 1881. 



640 DESCRIPTION AND TREATMENT OF INSANITY. 



b— PUERPERAL INSANITY. 

The puerperal condition is something more than a cause 
of mental derangement. It imposes certain features of its 
own, and hence gives rise to a peculiar form of insanity, dif- 
ferent in some respects from any other variety. 

For the purposes of the present inquiry, the puerperal 
state may be divided into three distinct periods— the first 
beginning with conception and ending when labor begins ; the 
second beginning with labor and ending with the cessation of 
the lochial discharge ; and the third embracing the time 
during which the mother nurses her child. These last two 
overlap each other about a month. In these days, when 
mothers do not always nurse their offspring, this third period 
is often absent. 

Period of Pregnancy. — During this period, although ex- 
alted forms of insanity are rarely met with, it is by no means 
uncommon to encounter various changes in the mental char- 
acteristics of the woman. These especially relate to the 
emotions and appetites. The likes and dislikes change ; un- 
reasonable prejudices against relatives and intimate friends 
are especially apt to be engendered, and the husband is not 
infrequently singled out for particular aversion and hatred. 

Morbid fears of various kinds take possession of the mind. 
In one case the patient acquired an unconquerabie fear of 
water ; she would neither drink it nor use it for purposes of 
cleanliness ; the very sight of it caused her the most poignant 
distress. 

In a case that came under my own observation many years 
ago, the patient, the wife of an officer of the army, during the 
second month of her pregnancy, became imbued with a fear of 
mice to such an extent that she adopted the most extraor- 
dinary precautions against them, and would not consent to be 
left alone even for a moment lest one of these animals should 
make its appearance. She always sat with her feet on an- 
other chair, and at night a fence was put up around the bed, 
as a means of restraint against her imaginary enemies. 

Again, there are fears that the anticipated child will be 
deformed, or that it will be too large to admit of being born. 
These are not merely temporary apprehensions, but are so 
firmly implanted as to cause mental derangement while they 
last. 



PUERPERAL INSANITY. 641 

Sometimes an excessive erotism approaching satyriasis is 
developed. Again, there are " longings" for various articles 
of food or drink, or for things which are not eaten or imbibed 
by well-ordered individuals. A desire for alcoholic liquors 
may constitute one of the " longings," and, if indulged, may 
result in the formation of a habit which it is afterward diffi- 
cult if not impossible to break. Earth, chalk, slate-pencils, 
paper, etc., are eaten with avidity. A patient of my own 
ate the ashes of the cigars smoked by her husband and 
brothers and left in the ash-holders, and another drank 
her own urine. These are, of course, perversions of the 
appetite for food, and rarely met with in other forms of 
insanity. 

The general mental type is that of depression approaching 
melancholia, but occasionally there is an exalted condition 
present which is as unreasonable as that of depression, but 
certainly less disagreeable. 

Illusions, hallucinations, or delusions are not especially 
liable to occur. 

In a few instances there is, as I have said, a more decided 
state of mental derangement produced, and this may be either 
of the maniacal or melancholic type, without any special char- 
acteristics. 

With the implication of the mind there are certain somatic 
symptoms of disordered cerebral action. These usually con- 
sist of headache, vertigo, and persistent wakefulness. 

As the pregnancy advances, all the phenomena mentioned 
tend to disappear, and by the sixth or seventh month are 
generally no longer apparent. 

Period of Labor. — It is at this time that puerperal in- 
sanity is most apt to be developed. It usually occurs during 
the first two weeks, sometimes during the process of delivery, 
again a few hours after the birth of the child, or it may be 
delayed for a month. 

Two forms of puerperal insanity occurring at this time are 
recognized : that of acute mania, and that of some one of the 
varieties of melancholia. The former is much the more com- 
mon type. 

It would scarcely be worth while, in view of what has 
already been said when the subject of acute mania was under 
consideration, to enter at length into the description of al] 
the features of an attack of puerperal mania of the acute 

41 



6±2 DESCRIPTION AND TREATMENT OF INSANITY. 

maniacal form. It will be sufficient if the peculiarities of the 
accession are brought to the notice of the reader. 

The first of these is such a change in the natural instincts 
of the mother as to cause her to acquire a feeling of the most 
determined aversion to the child of which she has just been 
delivered. This disposition has been observed by all authors 
on the subject. 

Esquirol, 1 in pointing out that the murderous tendencies 
of the puerperal maniac are not due to a desire which might 
exist of concealing the birth of a child, from shame or other 
like motive, refers to the case of a young woman who, being 
pregnant, made no secret of the fact, but got ready for her 
labor, and prepared the clothes for the child. The evening 
before her confinement she appeared in public. During the 
night she was delivered. The following morning she was 
found in her bed, but the infant was stuffed down the water- 
closet, and mutilated with twenty-one incisions and punctures 
with some sharp instrument, probably a pair of scissors. 
Shortly afterward she was arrested and carried on a stretcher 
a distance of two leagues from the house in which she was 
confined. During the journey she talked deliriously, and 
appeared not to know for what she was arrested. Several 
days subsequently she acknowledged her crime, but refused 
to eat. 

Morel cites the case of a woman, twenty- one years old, 
who had been delivered eight days previously, and who, when 
she came under his observation, was in a high state of mani- 
acal excitement, her eyes haggard, her hair dishevelled. "I 
am the devil ! " she said, throwing herself furiously on those 
around her. It was necessary to take away her infant, for 
she wished to strangle it. 

Fortunately, the opportunities for the subjects of puer- 
peral insanity to murder their infants are not many, but in 
two cases that have come under my charge the attempt to do 
so was made. In one, a woman who had been delivered of a 
male child, nine days previously, suddenly exhibited signs of 
mental aberration. The infant was removed to an adjoining 
room in charge of a nurse, but the mother got up in the mid- 
dle of the night, while her husband slept on a bed in another 
part of the room, and, going to where the child lay, seized it 

1 "De r alienation mentale des nouvelles accouchees etdes nourrices," "Des 
maladies mentales," t. i, 1838, p. 115. 



PUERPERAL INSANITY. 643 

by the neck, and attempted to strangle it. In the effort she 
nttered a cry, "Die, you hateful thing!" and so loud that 
the nurse awoke in time to save the infant' s life. 

In the other, the patient had become insane four days 
after delivery ; the child had been removed from her, but she 
expressed so urgent a desire to see it that it was brought 
to her. The instant she had it in her arms she dashed it 
toward an open window, about five feet distant. Fortu- 
nately^ the infant struck against the sill, and fell back into 
the room. 

But, in every other case, without exception — and they 
amount to fourteen in number — the patient has exhibited 
either active aversion to the infant or a passive indifference, 
fully as much at variance with the maternal instinct of love 
for her offspring manifested with more or less strength by 
the female of every species of the higher animals. 

Another peculiarity of the condition in question is the 
proclivity, which very generally exists in a marked degree, 
to make use of obscene language. Women who have been 
brought up in the most careful and refined manner utter 
words which are only heard from the mouths of the lowest 
specimens of civilized humanity ; and this not only occa- 
sionally, but in a continuous torrent, lasting for hours at a 
time. The wonder is, how they ever obtained the knowledge 
of the filthy expressions which flow with such fluency, and 
often without logical relation to each other. 

Dr. James Macdonald, 1 writing thirty-five years ago, in 
giving the details of one of his cases, calls attention to the 
repeated use of indecent words as a symptom very common 
in puerperal mania, and further says : " In the acute form of 
the mania which succeeds parturition, we observe an intensity 
of mental excitement, an excessive incoherence, a degree of 
fever, and, above all, a disposition to mingle obscene words 
with the broken sentences — things which are rarely noted 
under other circumstances. It is true that in mania modest 
women use words which in health are never permitted to issue 
from their lips ; but in puerperal insanity this is so common 
an occurrence, and is done in so gross a manner, that it early 
struck me as being characteristic. And is there no reason for 
it % Do not the disturbed uterine functions give rise to such 

1 "Puerperal Insanity," American Journal of Insanity, vol. iv, 1847-48, 
p. 113. 



(U-i DESCRIPTION AND TREATMENT OF INSANITY. 

ideas 1 " Dr. Campbell ' also remarks that the patient, though 
remarkably devout when sane, now launches out into such a 
torrent of obscene language that one is astonished that re- 
spectable females could have become acquainted with such 
expressions. 

Dagonet, 3 while expressing the opinion that there is noth- 
ing special about the insanity of the puerperal condition, 
says : "It is, nevertheless, to be remarked that the disorder 
of ideas is most intense, that the general excitation is more 
violent than is observed in other cases of mania, and that it 
is often complicated with dangerous irresistible impulses and 
erotic ideas. The patients, readily absolving themselves from 
all regard for the child they have brought into the world, 
perpetrate acts which are due to a perversion of the maternal 
feeling. The language they use is obscene, they endeavor to 
strip off their clothing, and their gestures and conduct toward 
those around them are scandalous." 

In addition, there is very often a strong disposition to 
suicide in the subjects of puerperal insanity, especially when 
it assumes the melancholic form. 

As to this latter form, there are present in it equally 
strong perversions of the maternal instinct, and tendency to 
erotic ideas, and the use of obscene language, as are observed 
in the maniacal type. 

Period of Lactation. — Insanity may be developed at any 
time during this period, or at a time soon after its cessation. 
It is not so common as the insanity of parturition, and pre- 
sents no very characteristic phenomena. It may be of the 
maniacal, melancholic, or monomaniacal type. Strictly speak- 
ing, the insanity of lactation is not a puerperal insanity, but, 
as it is generally so considered, I have introduced it here in 
order to present the subject in a complete form. 

Mental derangement from nursing may arise as a conse- 
quence of the increased weakness of the system, induced by 
the drain of milk in women of feeble constitutions. Again, 
it occurs at the time of weaning, apparently from the sudden 
stoppage of a function to which the organism has become 
habituated. 

All the forms of puerperal insanity are of hopeful prog- 

1 Journal of Psychological Medicine, January, 1859, p. 14. 

2 " Nouveau traite elementaire et pratique des maladies mentales," Paris, 1876, 
p. 500. 



PELLAGROUS INSANITY. 645 

nosis, provided the patients can be submitted to proper medi- 
cal treatment. 

The subject of etiology is not now under consideration, but 
it may be stated that, though albuminuria is sometimes pres- 
ent, there is no reason for supposing, with Sir James Simp- 
son, 1 that puerperal insanity, in any of its varieties of type 
or period, is due to ursemic poisoning. 

C — PELLAGROUS INSANITY. 

The disease which exists in Northern Italy and Southern 
France, known as pellagra, and which is an erythematous 
affection of the skin, is often accompanied by a peculiar form 
of insanity. The subject has been very thoroughly studied. 
Among many others by Strambio, 2 Brierre de Boismont, 3 
Baillarger,* Billod, 5 Sacchi, 9 Grintrac,* and Lombroso, 8 from 
whose writings I shall mainly quote what little I have to say 
relative to pellagrous insanity. 

There are many neurotic phenomena met with in indi- 
viduals affected with pellagra, but the most important is 
mental derangement. According to Billod, three fifths of 
all the insane in the asylum of Astino were pellagrous ; in 
that of Senarra, one third ; and a like proportion in the 
asylum of San Servolo, at Venice. 

Billod states that all the more typical forms of insanity 
are met with in pellagrous individuals. Thus, of two hun- 
dred and eighty cases in the asylum for women at Venice, 
there were of mania one hundred and eleven, of monomania 
six, of melancholia sixty -one, of stupidity ninety-seven, and 
of dementia five. This classification is, however, not very ex- 
act, and really gives us little information. 

The character of the insanity of pellagra is, according to 



Clinical Lectures on the Diseases of Women," New York, 1872, p. 561. 



1 u, 

2 "Due dissertazioni sulla pellagra," Milano, 1794. 



3 " De la pellagre et de la folie pellagreuse," Paris, 1834. 

4 " De la paralysie pellagreuse," Menu de Vacademie de med., Paris, 1848, t. 
xiii, p. 708. 

6 " Traite de la pellagre," Paris, 1870. 

6 "La pellagra nella provincia di Mantova," Eelazione della commissione pro- 
vinciate, Firenze, 1878. 

7 Art. " Pellagre," in Kouzeau dictionnaire de medecine et de chirurgie pra- 
tiques, t. xxvi, Paris, 1878, p. 447. 

8 " Stndi clinici ed esperimentali sulla natura, causa e terapeia della pellagra," 
Milano, 1870. 



6±6 DESCRIPTION AND TREATMENT OF INSANITY. 

the majority of writers on the subject, of a melancholic form. 
Gintrac thus describes it : 

"The cerebro-spinal symptoms consist of an alteration of 
the sensibility of the motility and of the intelligence. They 
are yertigo, pain, or rather a feeling of heat, along the spine, 
slight losses of consciousness, apathy, a great indisposition 
to muscular exercise or any sort of work. These symptoms 
gradually become more distinctly marked, the debility is 
more intense, the gait is staggering, the lower extremities be- 
come the seat of numbness, and of weakness which sometimes 
terminates in paralysis. At other times the pellagrous indi- 
viduals are subject to tremors, and to a degree of ataxia which 
renders their movements very uncertain and peculiar. They 
have, besides, hallucinations of sight and of hearing, they re- 
main obstinately silent, and preserve an immovable attitude. 
They have a slowness of speech, an incoherence of ideas, a 
sad delirium, a fixed idea of despair, and a degree of melan- 
cholia sometimes reaching to stupidity. In a word, they af- 
ford the sad spectacle of mental alienation, extending through 
all degrees, from simple hebetude to mania and monomania, 
and which often leads to suicide. 

Strambio, observing that the subjects of pellagrous insanity 
generally committed suicide by drowning, suggested the name 
of hydromania for this form of mental derangement. The in- 
tense heat of the skin excites not only directly to immersion 
in water, but also gives rise to delusions of fire, both in this 
world and in the next, and the miserable victims plunge into 
the water to extinguish at the same time the real and the 
imaginary fire. 

Gintrac adds that, in travelling through the districts in 
which pellagra exists, he has been informed that every year 
many pellagrous maniacs or melancholies are found drowned 
in the ponds. 

Baillarger finds in the phenomena of pellagrous insanity 
so many similitudes to general paralysis, that he insists on 
the existence of a striking analogy between the two diseases. 
These, however, are mostly as regards the somatic symptoms — 
the troubles of speech, the advancing paralysis. 

Lombroso regards the emotional impressionability of the 
subjects of pellagrous insanity as one of the most prominent 
characteristics of the disease. The slightest untoward event 
is sufficient to produce a degree of emotional disturbance 



CHOREIC INSANITY, ETC. 647 

altogether out of proportion to the exciting cause. Thus, a 
woman missing mass is thrown into a condition of despair, 
because she thinks she is in consequence doomed to eternal 
damnation. A man becomes acutely maniacal because a 
friend to whom he has lent a pistol will not return it ; and a 
woman becomes similarly affected because her husband, who 
is a fisherman, is a few minutes late in coming home. Some- 
times the patients remain obstinately mute for long periods ; 
refusal of food is common, as are various hallucinations. De- 
rangements of speech are also met with. Hydromania is 
among the most characteristic symptoms : some crave water 
for the cooling and refreshing influence which it has on the 
skin, others simply desire to see it. One patient told Dr. 
Lombroso that nothing in the world gave him so much pleas- 
ure as the sight of water. Occasionally some patients have 
a strong dislike for water. 

It appears to me, therefore, that pellagrous insanity 
should be regarded as a distinct pathological entity, the 
pathognomonic features of which are mental derangement, 
generally of the character of melancholia in some one of its 
forms, or of acute mania, and accompanied by the somatic 
phenomena of derangements of sensibility and motility, not 
unlike, in some respects, those which exist in general paral- 
ysis. 

The prognosis of the affection is bad. Eemissions may oc- 
cur, but the symptoms are almost certain to return with in- 
creased violence. 

$— CHOREIC INSANITY, ETC. 

Chorea is quite often accompanied by mental derangement 
of a peculiar kind. Keference is not made to the various 
epidemics of so-called chorea, which in former times appeared 
in various parts of the civilized world, nor to those other 
forms of disorderly movements which are more or less con- 
tagious or epidemic in character, and which sometimes ac- 
company great religious excitement. Some of them have 
been considered under the head of epidemic insanity. But 
by choreic insanity is to be understood solely the aberration 
of mind which is an accompaniment or a result of chorea, and, 
which is due to the same cause which produces the convul- 
sive disorder. 

The first to study the subject systematically was Marce, 



OiS DESCRIPTION AND TREATMENT OF INSANITY. 

and little has been added to onr knowledge of the snbject 
since the publication of his monograph over twenty years ago. 1 

Marce distinguishes four categories of phenomena con- 
nected with the mind which may exist in conjunction with 
chorea — troubles of the emotions ; of the memory and intel- 
lectual faculties generally ; of the perceptions ; and then 
maniacal delirium. The first three are, I think, observed with 
more or less completeness in all cases of chorea. In some in- 
stances they are slight, and may consist merely of defects of 
memory and weakness of the intellect in other respects ; but 
in others there are great emotional disturbance and almost 
constant hallucinations of sight. Without dwelling on these 
symptoms to any great extent, it may be well to call attention 
to them in a few words before proceeding to consider the 
more pronounced type constituting choreic insanity. 

The modifications of states of feeling which accompany 
chorea are in general well marked. The patient is irritable, 
impressionable, laughs in a silly way over circumstances not 
in the least risible, or sheds tears over events which are of the 
most inconsequential character. The tendency to deceive is 
developed to a surprising degree, and patients who have ordi- 
narily been remarkable for their truth- telling quality and 
freedom from subterfuge and fraud, will lie with and without 
reason, and resort to altogether unnecessary tricks and cheats, 
actuated apparently by no other motive than a kind of auto- 
matic spirit of falsehood. It is possible that in some cases 
the stories that are concocted by choreic children have their 
origin in delusions which are mistaken by them for actual 
occurrences. 

So far as the intellect is concerned, the principal aberra- 
tions are perceived as regards the memory and the power of 
concentrating the attention. Nothing seems to make any 
permanent impression on the understanding, though, as we 
have seen, the emotions are affected readily enough. Learn- 
ing lessons at school becomes an impossibility. The child 
can neither apply itself nor retain the little it may acquire. 
These phenomena indicate a condition of mental weakness 
approaching dementia, and, indeed, the state of mind induced 
is in some cases as well-marked dementia as is ever seen. 

1 " De l'etat mental dans la choree," " Memoires de l'academie imperiale de 
medecine," t. xxiv, 1860, p. 1 ; also, " Traite pratique de maladies mentales," 
Paris, 1862, p. 576. 



CHOREIC. INSANITY, ETC. 649 

In some very severe cases of chorea the mental manifesta- 
tions are very profound, and a state of stupor is induced, dur- 
ing which the patient is more or less insensible to what is 
going on around him. 

Indeed, it is almost invariably the case that the mental 
aberration is in direct relation with the somatic symptoms. 
When these latter are at their height the disturbance of mind 
is always greatest, and, when they are diminished in violence, 
the mind tends to the resumption of its normal condition. 

Marce states that it is not rare to meet with hallucinations 
in chorea. Except in cases of fully developed choreic insan- 
ity, few cases of the kind have come under my observation, 
and these, all except one, related to the sense of sight. In 
this respect my experience is in accordance with that of 
Marce, who states that he has never seen the sense of taste 
or of smell involved, and only one case in which the hearing, 
and three in which the touch were affected. Hallucinations 
in chorea are, as he states, more frequent between the ages of 
fourteen and twenty-four years than at other times. In very 
young patients they are never seen. Of forty patients exam- 
ined by Marce, eleven had hallucinations of sight. Of the 
very many cases of chorea which have been under my obser- 
vation and treatment in hospital and private practice, thirteen 
only exhibited sensorial aberration unaccompanied by the 
manifestations of acute mania. 

As Marce has pointed out, the peculiarity of choreic hallu- 
cinations is, that they are not present during the state of 
wakefulness or when the eyes are open, but only appear in 
that period between sleeping and waking, which occurs when 
the patient is going to sleep or when he is about awaking. 
The moment he shuts his eyes in the process of going to sleep, 
they occur ; and again they may — bnt not with the same de- 
gree of frequency — make their appearance just as he is about 
to open his eyes on awaking. Marce had one case in which 
hallucinations appeared during the day whenever the patient 
shut his eyes. 

The images are of all kinds — friends, relations, demons, 
angels, all kinds of deformed persons, giants, dwarfs, and 
every variety of animals. Sometimes when some person has 
been vividly brought before the mind, the image of that per- 
son appears as a hallucination, and persists for a long time. 

Occasionally the hallucinations appear before there are 



050 DESCRIPTION AND TREATMENT OF INSANITY. 

any convulsive movements ; in other cases they occur only 
when the paroxysms are most intense. 

Of fully developed choreic insanity, only five cases have 
come under my observation. Three of these are referred to 
in another place, 1 and two have occurred in my experience 
during the past two years. It may make its appearance at 
any time during the course of the disease, and sometimes, as 
in one of my cases, before there are any convulsive move- 
ments. In most cases, however, it does not supervene till 
after the tenth day. So far as my observation extends, the 
essential points of difference between it and the ordinary 
form of acute mania are the occurrence of the hallucinations 
only at the time of going to sleep or awaking, and the exist- 
ence of a peculiar species of incoherence characterized by the 
utterance of isolated words, which have no relation whatever 
to each other. Marce alludes to this symptom. It appears 
to be due to the excessive rapidity with which hallucinations, 
illusions, and delusions succeed each other — a rapidity 
which is never in my experience equalled in acute mania of 
the usual type. 

Thus, in a young lady of seventeen, who came to me from 
a neighboring city, mental derangement had supervened on 
the sixth day after the occurrence of choreic movements. 
These had gone on rapidly from the very beginning, augment- 
ing in violence every hour till they involved her head, arms, 
legs, and trunk. On the sixth day she became violently ex- 
cited in consequence of hallucinations of sight, which effect- 
ually prevented her sleeping. The moment she closed her 
eyes, old men and women, with black imps, appeared to be 
dancing round her, and pointing their fingers at her in de- 
rision. She could hear them laugh, as they capered around 
her in all possible combinations of dancing figures. After a 
night, during which she was entirely without sleep, delusions 
ensued, and her maniacal disturbance was still greater. Then 
she began to talk, but in such a way that no one could under- 
stand what she said. It seemed, as her mother said, as though 
she had taken a thousand pieces of paper with words on them, 
and, after shaking them all together, was naming them off one 
by one. 

On the tenth day of the attack, I saw her at her hotel in 

1 " A Treatise on the Diseases of the Nervous System," seventh edition, New 
York, 1881, p. 732. 



CHOREIC INSANITY, ETC. 651 

this city. She was then in a state of great exaltation, and the 
choreic movements were at their height. Two persons were 
necessary to keep her in bed, as, on the least relaxation of 
their vigilance, she would attempt to leave the room, and 
once had tried to get out of the window. She was talking at 
the top of her voice, but this was not high, as exhaustion was 
rapidly advancing, and she was then very weak, but, though 
she spoke distinctly enough, there was nothing but a string 
of disconnected words without the slightest relation to each 
other. At times she would close her eyes, as if about to sleep, 
but instantly would start up, frightened, and would begin to 
talk apparently with the object of saying something in regard 
to her hallucinations, but with the same utterance of unrelated 
words. 

Conceiving the case to be one requiring prompt treatment, 
I put her under the anaesthetic influence of ether, with the 
effect of quieting both her mental and physical manifesta- 
tions, and procuring for her the first good sleep she had had 
for several days. By means of the hypodermic administra- 
tion of morphia and arsenic, she made a good recovery in 
about three weeks. 

In another case, occurring in a young lady of this city, 
whom I saw in consultation with the late Dr. Henschel, 
violent chorea, with maniacal manifestations similar to those 
of the case just cited, was developed by the excitement con- 
sequent on a visit to the dentist. In this instance, a like 
means was successful in immediately quieting the patient, 
who ultimately recovered under the use of arsenic and bromide 
of sodium. 

In connection with choreic insanity, there are very gener- 
ally pain in the head, frequent attacks of vertigo, acceleration 
of pulse, and increased bodily temperature. 

There are other alleged constitutional forms of insanity, 
but they are not included here, for the reason given on page 
292. It is very well to speak of alcoholic insanity, malarial 
insanity, syphilitic insanity, and so on for a dozen or so more, 
but all these are simply instances of insanity of different 
types produced by alcohol, malaria, etc. It would be just as 
proper to regard traumatic insanity as a separate form of 
mental alienation, though it is well known that any of the 
varieties of insanity may have wounds and injuries for its 
exciting causes. 



652 DESCRIPTION AND TREATMENT OF INSANITY. 

CHAPTER IX. 

THE CAUSES OF INSANITY. 

Predisposing Causes. — The causes of insanity have been 
to a great extent considered in the earlier- chapters of this 
work, so that it will not be necessary to do more in the pres- 
ent connection than to apply the principles there laid down, 
and to bring forward such other factors as are proper in illus- 
tration of the subject. Thus, under the heads of Habit, 
Temperament, Idiosyncrasy, Constitution, Sex, Race, Age, 
the influence of these agencies in producing mental derange- 
ment have been sufficiently dwelt upon, but there are a few 
others of what may be called the predisposing causes that 
require some consideration at this time. 

Civil Condition. — The civil condition, as regards marriage 
or celibacy, is important in its etiological relations to in- 
sanity. The statistics of all civilized countries show a larger 
proportion of lunatics among those who are unmarried than 
among those who are married. In France, according to Da- 
gonet, 1 there is one insane person to every 528 celibates over 
the age of fifteen, while among those who are married the 
proportion falls to one in 1,523. In large cities, the propor- 
tion of single women who become lunatics is greater than in 
single men. In the widowed, the proportion is one to 942. 

Of 1,426 patients admitted into the Colney Hatch Asylum, 
England, during four years, the proportion was about equal, 3 
but then, as the married persons in England and Wales, ac- 
cording to the census of 1871, are more than twice as numer- 
ous as the single persons, it follows that the proportion of 
lunatics existing among single persons is about double that 
among the married. 

Most of the asylum reports of this country show like re- 
sults. Taking one of the latest, that of the Illinois Eastern 
Hospital for the Insane at Kankakee, we find that of 424 
patients admitted during the years 1881-83, 209 were single, 
152 married, 29 were widowed, 17 divorced or separated, and 
of 17 the civil condition was unknown. 

Upon this point there is a general accord among writers 
on psychological medicine. 

1 Op. cit., p. 473. 

2 Bucknill and Tukes's " Manual of Psychological Medicine," London, 1879, 
p. 88. 



. i THE CAUSES OF INSANITY. 653 

Civilization.- r It is the generally received opinion that in- 
sanity is much more common among civilized nations than 
among those who are lower in the scale of enlightenment. It 
is difficult to arrive at any very exact conclusion in regard to 
this point. In the first place, as nations advance in intelli- 
gence and refinement, the insane are more readily recognized 
than they are among barbarous and savage peoples,' or even 
than they were among ourselves a few years ago. Not long 
since no one was regarded as insane who was not either a jab- 
bering idiot or a raving maniac. The individual who, under 
the influence of a morbid impulse which he could not resist, 
killed some one, was held to be responsible, and was punished 
accordingly. Such forms as morbid impulses, and many 
others, were not known. The individual who acted in accord- 
ance with them was supposed to have been " moved and in- 
stigated by the devil," and in all probability went to the stake 
for allowing himself to be subdued by satanic power. To 
say, therefore, that the number of the insane has increased 
with the advance of civilization is in reality only alleging that 
more insane are known to exist than formerly ; and another 
factor in adding to the number is the increased facility for 
discovering instances of mental derangement, Rowing to the 
development of the means for intercommunication. ' 

Again, though additional influences capable of causing in- 
sanity are probably furnished by a higher state of civilization, 
it must not be forgotten, on the other hand, that many influ- 
ences due to a low degree of civilization have been eliminated. 
People are better fed, clothed, and housed than they were 
two or three hundred years ago. And, again, among barba- 
rous or savage nations, or those persons among civilized peo- 
ples whose minds are not developed up to a high standard, 
slight causes which would be of no effect in persons of edu- 
cated minds are often influential in causing insanity. An 
ignorant person will, therefore, become insane from the action 
of a cause that would scarcely ruffle the equanimity of an 
educated individual. 

. But, whatever value is to be attached to these suggestions, 
\the fact remains undisputed that there are more known cases 
of insanity at the present day than there were, for instance, 
fifty years ago: According to Marce, the proportion of luna- 
tics to the population was in Europe, in 1836, one to 3,080, 
while, in 1851, fifteen years later, it was one to 1,676, not far 



651 DESCRIPTION AND TREATMENT OF INSANITY. 

from double. Lunier states that the rate has in France pro- 
gressively advanced. A part of this increase is undoubtedly 
due to increase of population, but, making all reasonable 
allowance for this circumstance, there is still a large margin 
left. 

It has been stated, but I do not know whether or not on 
satisfactory evidence, that since the abolition of slavery in 
the United States the number of the insane among the negroes 
has very greatly increased. 

Cities. — Large collections of people in one place certainly 
tend to the increase in the number of the insane. The larger 
the city, and the more the inhabitants are crowded together, 
the greater, other things being equal, will be the number of 
the insane. 

Exciting Causes. — The exciting' causes are those which 
stand to the disease as its immediate producers. They are 
very numerous, and the influence of some that are generally 
considered to be strong factors in giving rise to insanity is 
very questionable. 

Emotional Causes. — These are undoubtedly the most efficient 
of all the exciting causes of insanity. Their action is gen- 
erally prompt and easily recognizable. Chief among them is 
anxiety, which, however, is more frequently a secondary 
emotion than one of primary action. A person, for instance, 
becomes insane, it is supposed, from love, but it in reality is 
not lorn that is the causative emotion, but anxiety lest the 
passion felt is not reciprocated. As soon as all doubt on this 
point is removed, whether by a favorable or an unfavorable 
termination, the anxiety disappears, and the condition of the 
patient becomes much more tolerable. 

AgaiUf a man engaged in business, and having constant 
need for large sums of money to meet his engagements, suf- 
fers the keenest anxiety day after day, to a greater or less 
extent, throughout his life. He is never quite sure that he 
will obtain the funds he requires, and hence the strain upon 
his mind is so great that it is not at all singular that it often 
gives way and that insanity is the result. On the other hand, 
if he does not get the money he needs, and bankruptcy fol- 
lows, there is at once a relief from the strain, and comparative 
mental repose follows. The uncertainty and anxiety are far 
more apt to lead to mental alienation than the assurance of 
disaster. 



THE CAUSES OF INSANITY. 655 

Almost all the domestic chagrins to which Esquirol at- 
tributes so great an influence in the causation of insanity are 
only forms ,of anxiety. The father of a family, feeling the 
responsibility that rests upon him, is anxious relative to his 
ability to clothe, feed, and house his wife and children. A 
son or a daughter gives evidence of vicious inclinations, and 
again anxiety to one or both parents is the result. I am ac- 
quainted with the particulars of a case in which both the 
father and mother became insane in consequence of the 
anxiety felt in regard to the guilt or innocence of a son 
accused of highway robbery, but upon whom the crime 
was never proved. They neither of them believed in his 
culpability, but the anxiety as to the result of his trial, the 
doubt and uncertainty, were more than their minds could 
endure. 

Anxiety in regard to political success is in this country 
not an infrequent cause of mental derangement.' .The tenure 
by which fortunes are held is often so slight, the ways by 
which they are obtained are often so uncertain, the risks are 
so great, the profits so large, that those who plunge into the 
vortex of "business," as it is called, often come out perhaps 
with a million or more of money, but with a mind shattered 
past recovery. 

Chagrin, or active corroding grief, is also a prolific cause 
of mental derangement scarcely second to anxiety in power. 
Here, again, family and business affairs stand pre-eminent as 
the producers of the emotion. With some people, those in 
whom the hereditary tendency is strong, very slight causes 
are sufficient to produce intense grief, and consequent in- 
sanity. The case of a lady is within my own experience in 
which intellectual subjective morbid impulses were produced 
by the grief resulting from a leak in the bath-room, which 
ruined a finely-painted ceiling. She became wakeful, had 
pains in her head, and kept constantly repeating the words 
she had uttered when she saw the wreck that had been 
caused: "My God, it will cost a thousand dollars to repair 
it ! " Night and day these words were passing through her 
mind, as in the cases mentioned under their proper head. 

In another case, from the chagrin and disappointment re- 
sulting from failure to receive an office from the Government, 
for which he had been an applicant, a gentleman became 
affected with acute mania. In another instance, from a like 



656 DESCRIPTION AND TREATMENT OF INSANITY. 

cause, the resultant form of insanity was melancholia with 
stupor. 

Fright and terror are also powerful emotional causes of 
mental aberration, and cases due to their action are common 
enough. Probably the forms most apt to be produced by 
them are the several varieties of melancholia, hysterical in- 
sanity, epileptic insanity, and acute mania. 

Love. — Whatever may have been the power of this emo- 
tion, primarily acting, to cause insanity, its influence is being 
gradually extinguished. Forty-five years ago Esquirol ' said 
that, however frequently love might be the cause of eroto- 
mania, or even of nymphomania, in warm climates, its empire 
in France is lost. The indifference of the sexes to each other, 
and the fact that amorous passions have neither the exalta- 
tion nor the purity requisite to the engendering of erotomania, 
have extinguished the influence it once had. Though things 
are not so bad as this in the United States, it is very certain 
that love is no longer the romantic feeling which it was fifty 
or even a less number of years ago. Marriage is now generally 
a business venture, into the arrangements for which love, as 
a passion, very rarely enters. This is even more true of men 
than of women, many of whom yet have some degree of sen- 
timent in their organizations. The facilities which men have 
for gratifying the passions in an illicit manner, without as- 
suming the responsibilities and expense of an establishment 
with a wife and children, are factors which are continually 
tending to lessen the power of virtuous love, and to reduce 
the number of marriages. I have never seen a case of mental 
or physical disturbance reaching the point of disease in a 
man from the effect of love, or of any disappointment 'Conse- 
quent thereon. 

It is scarcely necessary to specify particularly each emo- 
tion which is competent to produce insanity. There is not 
one which has not this power. There is no uniform manner of 
acting. An emotion of one kind may produce acute mania 
in one person, melancholia in another, intellectual monomania 
with exaltation in a third, katatonia in a fourth, general 
paralysis in a fifth, and so on. Indeed, the same emotion 
may at different times, in the same individual, produce differ- 
ent varieties of insanity. 

Intellectual Causes. — The only intellectual factor in the pro- 

1 "Des maladies mentales," Paris, 1838, t. i, p. 31. 



THE CAUSES OF INSANITY. 657 

duction of insanity requiring consideration is that of excessive 
mental exertion. Doubtless it is true that, under certain 
circumstances, the undue concentration of the mind upon any 
particular line of thought will lead to mental aberration ; 
but such cases are rare, mainly for the reason that there are 
comparatively few persons who use the intellect to excess in an 
abnormal way. The brain, like the rest of the body, is meant 
for work, and it is capable of enduring a great deal of labor 
without suffering. It is only when this is carried on regard- 
less of the laws of health, relative to physical exercise, food, 
sleep, etc., that disease is liable to ensue. The person who 
works with his brain in overheated or badly ventilated apart- 
ments, who encroaches on the hours that should be given to 
sleep, and who attempts to do his work on an improper or 
insufficient diet, will run great risks of mental derangement. 
By depriving himself of sleep, he is giving the brain no suffi- 
cient opportunity to rest, and to repair the waste produced by 
his mental labor ; and, by keeping his brain in action up to 
the very moment of going to bed, he induces a hyperemia of 
the organ, which renders sleep impossible. Then he begins to 
suffer, and then it is that the danger of insanity is incurred. * 
But the employment of the brain in any congenial work for 
eight or ten hours a day, with sufficient opportunities for 
relaxation, will very rarely lead to mental disease. There is 
more danger in the case of children, whose nervous systems 
are undeveloped, whose whole surplus strength is required 
for growth, and who are often unduly tasked at school with 
subjects above their comprehension, and with a variety of 
studies which keep the brain in a continual state of erethism. 
In them, therefore, it is no matter for astonishment to find 
headache, insomnia, vertigo, even when they are at rest, and 
an aggravation of all the symptoms on the least attempt at 
mental concentration. Most physicians in the larger cities 
meet with such cases in large numbers, and with not a few 
in which positive insanity is the ultimate result. 

Physical Causes. — The physical causes of insanity are very 
numerous. They embrace those which are external to and 
those which are inherent in the individual. Among the first 
are the following : 

Certain ingesta, either taken as food or as medicine, are 

1 This subject is discussed with sufficient fulness in the chapters on sleep, to 
which the reader is referred. 
42 



058 DESCRIPTION AND TREATMENT OF INSANITY. 

exceedingly potential in the causation of insanity. Chief 
among these is alcohol. 

It is not the intention here to speak of the influence of al- 
cohol as it affects the brain immediately after its ingestion, or 
of the blood-poisoning which it produces in a more chronic 
form. These states are known as acute and chronic alcoholic 
intoxication, and are described in works devoted to the con- 
sideration of diseases of the nervous system, or to the general 
practice of medicine. 1 But it is the purpose to consider briefly 
the influence of alcohol in causing insanity independently of 
its immediate toxic influence due to the circulation of poi- 
soned blood through the system, especially the brain. 

That alcoholic liquors when taken to excess have this 
power is so well known that it is not a matter to be substan- 
tiated by the citation of authorities. Almost every form of 
insanity, from simple sensorial aberrations to general paral- 
ysis and epileptic insanity, may result from the inordinate use 
of alcoholic liquors. At one time I was disposed to think 
that they gave rise to a special form of mental derangement, 
to which the term alcoholic insanity could properly be ap- 
plied ; but continued observation and study of the subject 
have convinced me that there is nothing peculiar in the 
mania, melancholia, general paralysis, or any other form of 
aberration of mind caused by these agents, and that such a 
disease as alcoholic insanity, with special characteristics, 
does not exist. Marfaing, 2 among others, has described such 
an affection, and has given many interesting particulars of 
the disorder which he thinks he has differentiated. Thus, 
he contends that the hallucinations and delusions are almost 
always of a painful character. The patient sees frightful 
or repulsive objects, armed men, or horrible animals ; he sees 
persons lying in wait for him, or a thousand obstacles are 
interposed between him and his desires ; he hears menacing 
voices, and the supplications of his friends from dangers 
which encompass them. 

Occasionally, however, the imaginings are of a more pleas- 
ant character. He is surrounded with flowers and fountains, 

1 See chapter on " Alcoholism " in the author's " Treatise on Diseases of the 
Nervous System," seventh edition, New York, 1881, p. 894 ; also, " Effects of 
Alcohol on the Nervous System," Neurological Contributions, No. 2, 1880, p. 29. 

2 " De l'alcoolisme considere dans ses rapports avec l'alienation mentale," 
Paris, 1875. 



THE CAUSES OF INSANITY. 659 

beautiful women are his companions, and, though his genera- 
tive powers may be entirely extinct, he brags of his con- 
quests, and of the favors which are showered upon him. 

Another characteristic, according to Marfaing, of the hal- 
lucinations and delusions of the mania of alcoholism, is their 
changeability. Scarcely has he expressed one delirious con- 
ception than another is uttered, and so on for days at a time. 

Now there is nothing at all characteristic in these phe- 
nomena. They are met with in melancholia with delirium, 
and in acute mania, no matter by what factor they are pro- 
duced. 

I have witnessed many cases of so-called alcoholic in- 
sanity, and I am forced to say that, after a full consideration 
of its symptoms, I have seen nothing typical in it. The acute 
mania, or melancholia, or general paralysis, or whatever it 
may be, presents no distinguishing features. For instance, va- 
rious morbid fears, not distinguishable from those considered 
under the head of " emotional monomania" as resulting from 
other causes, are produced by alcohol. Thus, a gentleman 
whose case came under my charge, becoming addicted to the 
excessive use of alcoholic liquors, gradually contracted the 
fear that he would say something profane or obscene if he 
ventured into the presence of ladies, and hence he shut him- 
self off from female society. Upon one occasion, he found 
himself accidentally in the company of a lady of his acquaint- 
ance, when he threw up his hands in horror, exclaiming : 
4 'For God's sake, go away, or I shall be compelled to insult 
you in the grossest manner ! Go, go, go ! " advancing toward 
her at the same time, and actually turning her out of the room. 

Again, there is intense melancholia without the existence 
of delusions, and differing in no essential respect from the 
simple melancholia already described, during which the indi- 
vidual may attempt suicide or self -mutilation. Or there may 
be indefinable fear, despair, terror, shame, or some other form 
of emotional monomania, leading to the perpetration of self- 
destruction. " Intellectual monomania with depression," at- 
tended with delirium of persecution, is also a common result 
of excessive alcoholic indulgence. 

But perhaps the most common of all the forms of insanity 
caused by alcohol is general paralysis. All authors recog- 
nize its influence in this direction. Drs. Bucknill and Tuke ' 

1 "A MaDual of Psychological Medicine/' fourth edition, London, 1879. 



660 DESCRIPTION AND TREATMENT OF INSANITY. 

place it in the front rank. " Drink causing poverty and pov- 
erty leading to drink (the former in by far the larger propor- 
tion of cases) are the familiar antecedents of an attack of 
general paralysis." 

Mickle 1 names " alcoholic excesses" first in the list of 
causes. In my own experience it takes precedence of all 
other known causes, fully twenty per cent of the cases that 
have come under my observation being due to alcoholic 
liquors used to excess. 

A somewhat peculiar variety of insanity is, however, pro- 
duced by the drinking of absinthe, a habit which prevails to 
a great extent in France, and one that has many votaries in 
this country. 

The condition in question has been well studied by M. 
Magnan, by experiments on the lower animals as well as by 
observations in man. The main fact appears to be that ab- 
sinthe has an especial proclivity to produce epileptic convul- 
sions, in addition to causing the other phenomena of insanity, 
due to the highly concentrated alcohol it contains. 

Certain fungous growths, which affect grain used as food, 
are apparently productive of insanity. Thus, in those coun- 
tries in which ergotized rye is eaten for long periods by the 
inhabitants, a peculiar condition, characterized by physical 
and mental phenomena, is produced. The forms of insanity 
have nothing special about them. In the beginning there 
may be several epileptiform paroxysms, followed by coma ; 
or, without these, the patient passes into a condition of de- 
mentia, or of more or less permanent insanity. Sometimes 
it is acute mania, again, melancholia in some one of its 
forms, especially that with stupor, which is developed. 2 

For a long time it was supposed that Indian corn, or maize, 
was the chief if not the only agent in the causation of pella- 
gra. The fact that millions of people in the United States 
eat no other bread than that made from Indian corn, and that 
they ingest this substance in some form or other in large 
quantities several times a day, not only without contracting 
pellagra or any other disease, but with the most evident signs 
of resultant good health, appears to have been overlooked. 

1 " General Paralysis of the Insane," London, 1880, pp. 101, 103. 

,J Schleger, "Versuchen mit dein Mutterkorn," "Memoir of the Medical 
Faculty of Marburg," Oassel, 1770 ; also, Hursinger, " Studien uber den Ergotis- 
mus," Marburg, 1856. 



THE CAUSES OF INSANITY. 661 

More recently, however, it was ascertained, with a tolerable 
degree of certainty, that the Indian corn used in Northern 
Italy and Southern France is subject to the growth of a fun- 
gus. This liability appears to be due to the climate, and to the 
peculiar method employed in storing the grain. Gubler, 1 in 
a report made to the French Academy of Medicine on Fua's 
work on the hygienic and therapeutical properties of maize, 
states that when the grain is of good quality it produces no 
deleterious result, and that it is as absurd to charge it with 
causing pellagra as it would be to ascribe ergotism to healthy 
rye. He declares, however, that, when the grain is changed 
either by the products of decomposition or by the growth of 
low organisms upon it, it acquires poisonous properties, and 
may then be productive of pellagra and pellagrous insanity. 

Nevertheless, there are many authors who do not consider 
maize in either its healthy or diseased state as responsible for 
pellagra. The fungus supposed to give rise to pellagra is 
known to botanists as the sporisorium mayais. 

Certain medicines, such as morphia, chloral, the bromides, 
belladonna, and other substances, give rise to mental de- 
rangement when taken in excessive or long-continued quan- 
tities ; but it appears to me scarcely advisable to consider the 
delirium, dementia, or other phenomena of the derangement of 
mind from their use as separate and distinct forms of insan- 
ity. There is hardly a medicine in the whole materia medica 
that is not capable of influencing the mind in an abnormal 
manner ; indeed, some of the most bland and nutritious arti- 
cles of food will, under certain circumstances, do the same 
thing. I have had many opportunities Bf witnessing instances 
of mental derangement due to the use of morphia, chloral, 
and the bromides, and have never seen anything sufficiently 
characteristic to warrant the creation of a morphia, chloral, 
or bromide insanity, any more than there is for the creation 
of the insanity due to alcohol, into a distinct form. Either of 
these substances may produce any variety of mental aberra- 
tion. 

Several years ago I a reported a number of cases in which 
large quantities of the bromide of potassium had caused in- 

1 " Bulletin de Pacademie de m6decine," avril 9, 1878. 

2 " On some of the Effects of the Bromide of Potassium when administered 
in Large Doses," Quarterly Journal of Psychological Medicine, New York, 
January, 1869, p. 46. 



662 DESCRIPTION AND TREATMENT OF INSANITY. 

sanity. In one of these the patient for several days, at his 
own suggestion, took an ounce a day. ' ' He was now decid- 
edly insane ; had delusions that lewd women had got into 
his mother's house ; that he was pursued by the police ; that 
his life was threatened by members of the family ; that he 
had thousands of dollars in gold sewed up in his clothing, etc. 
. . . His manner was excited and rambling, and his hands 
either busy in fumbling in his pockets, picking threads from 
his clothing, or in searching for the gold which he believed 
was concealed in the lining of his coat. His character had 
also undergone a radical change. From having been very 
frank and brave, he had become excessively timid and suspi- 
cious of every trifling circumstance. . . . His symptoms were 
in many respects so much like those of an ordinary attack of 
acute mania, and his antecedents were of such a character, 
that I had reason to doubt the influence of the bromide in 
causing them. It was found, however, that he had secreted 
large quantities of it in various out-of-the-way places about 
the house. 

"His mental symptoms had now become so prominent 
and constant, that his friends became alarmed for their own 
and his safety. He had several times attempted to throw 
himself from the window, and had battered down a door with 
an axe in order to escape from some imaginary danger. Un- 
der these circumstances I recommended his committal to a 
lunatic asylum, and he was accordingly removed to Sanford 
Hall, at Flushing. Here his symptoms gradually disappeared, 
and in a month he returned to his home well." 

In another case, a lady, melancholia with delirium was the 
result. The memory was destroyed ; she would burst into 
tears without cause, thought that she was deserted by her 
friends, that her child was dead, etc. In another case, of a 
lady, similar symptoms resulted, as they did also in the in- 
stance of a gentleman. In all these cases the remedy was 
given in medicinal doses. 

Nothing characteristic was observed in any of these cases. 
Since they were reported, several others have come under my 
notice, and, while the prevailing type of insanity has been 
melancholia, it has been in no respect different from forms 
due to very different causes. 

Again, the appetite for stimulants or narcotics has been 
called, according to its character, metJiomania or dipsomania, 



THE CAUSES OF INSANITY. 663 

morpMomania, chloralmania, and so on. I do not regard 
these disturbances of the appetites as insanity, and therefore 
they have not been considered in this work. 

Wounds and Injuries of the Head are common causes of 
insanity, and very slight blows may, even after long periods, 
result in mental derangement. Esquirol, 1 in considering this 
subject, says: 

u Falls on the head, even during the first years of infancy, 
predispose to insanity, and are sometimes its exciting cause. 
These falls or blows on the head may precede by many years 
the explosion of the insanity. A child of three years fell on 
its head ; from that time there was headache, which at pu- 
berty became more pronounced, and at the age of seventeen 
mania occurred. A lady riding on horseback was thrown ; 
some months afterward she became insane. In three months 
she was cured, but she died two years subsequently of brain- 
disease." 

Dr. Rush a says : 

" A young man died in the Pennsylvania Hospital in the 
year 1809, who became deranged at twenty-one in consequence 
of a contusion on his head by a fall from a horse in the fif- 
teenth year of his age. A Mr. died of madness in the 

same place, from an injury done to his brain, by being thrown 
out of his chair, between two and three years before he dis- 
covered any signs of derangement. It is remarkable that in- 
juries show themselves more slowly in the brain than in other 
parts of the body. Dr. Lettsom mentions a case, in the ' Mem- 
oirs of the London Medical Society,' of a disease of the 
brain induced by a fall from a horse, which did not discover 
itself until two-and-twenty years after its occurrence." 

The subject of traumatism, as a cause of insanity, has been 
well studied in recent times. Kafft-Ebing ' insists with much 
force upon the fact that, in those cases in which the insanity 
is delayed in making its appearance, the injury has only 
acted as a predisposing cause, which requires some other fac- 
tor to further develop. Schlager, 4 however, who bases his 
observations on forty -nine cases of traumatic insanity in five 

1 Op. cit., p. 33. 

a " Medical Inquiries and Observations upon the Diseases of the Mind," Phila- 
delphia, 1830, p. 28. 

3 " Lehrbuch der Psychiatric" 

4 " Zeitschrift der k. k. Gesellschaft der Aerzte zu Wien," B. xiii, 1857, p. 454. 



Q04: DESCRIPTION AND TREATMENT OF INSANITY. 

hundred lunatics, states that, in general, the patients ex- 
hibited from the time of the injury a tendency to cerebral 
congestion. In my own experience, I think, I can go further 
and say, that not only was a tendency exhibited, but that 
cerebral congestion was actually present from the time the 
injury was received. 

In an interesting paper, Dr. Kiernan, 1 of Chicago, considers 
the influence of traumatism in causing insanity. He arrives 
at the conclusions from the consideration of forty-five cases 
occurring in his own experience, as well as of many reported 
by other authors : 

"First, that traumatism produces certain psychoses. 

" Second, that the majority of these are unaccompanied 
by epilepsy. 

" Third, that the majority have a tendency to end in pro- 
gressive paresis. 

" Fourth, that a large proportion are accompanied by de- 
pressing delusions. 

" Fifth, that the majority of these latter do not exhibit 
any hereditary taint. 

u Sixth, that, with certain modifications, Krafft-Ebing's 
conclusions respecting the traumatic psychoses are correct. 

" Seventh, that injuries received before the age of forty 
are probably of more effect in producing insanity than those 
received subsequently. 

" Eighth, that slight injuries, from the insidious nature of 
the changes they set up, are as much to be dreaded as, if not 
more than, the grave injuries. 

" Ninth, that traumatic causes did not have as much influ- 
ence in the production of insanity as intimated by Schlager, 
he finding that over eight per cent of the cases were caused 
by traumatism, while at the New York City Asylum for the 
Insane but two per cent were so caused. 

" Tenth, that certain cases of insanity caused by trauma- 
tism have been well-marked, systematized delusions. 

" Eleventh, that in all cases of insanity caused by trauma- 
tism a guarded prognosis should be given." 

Dr. Uritz, a of Chicago, reports an interesting case in which, 
soon after a severe blow on the head received by a man of 
about fifty years of age, a radical change of character super- 

1 Journal of Nervous and Mental Disease, July, 1881, p. 445. 

a American Journal of Neurology and Psychiatry, May, 1882, p. 196. 



THE CAUSES OF INSANITY. 665 

vened, which, was followed by hallucinations, delirium of an 
exalted character, and acts of violence. Shortly afterward 
he committed suicide. On post-mortem examination, the mem- 
branes were found to be adherent to each other, to the cortex, 
and to the skull. 

In a case, in my own experience, a boy at the age of 
twelve fell from a tree and struck his head. He was taken 
up senseless, but recovered. For a year or more, he suffered 
from headache, but he passed the period of puberty safely. 
At twenty-five, thirteen years after the injury, he became 
acutely maniacal, and died before the end of the third month. 
On post-mortem examination, adhesions of the membranes 
to the skull and to the brain were found to exist at the seat 
of injury, and there were other indications of inflammation 
and congestion. 

In 1868 I examined a boy of about seven years of age, at 
Metuchen, in New Jersey, in consultation with Dr. Hunt, of 
that place. He had periodical attacks of acute mania, in 
which he was extremely violent and destructive. During 
early infancy — four years previously — he had had a severe 
fall, and upon consideration it was decided to trephine at 
the supposed seat of the injury. I performed the operation, 
but no fracture was found. There was, however, an abnor- 
mal degree of thickness of the skull at that place. The boy 
made a good recovery, and the paroxysms ceased. 

In the case of a boy, aged eighteen, who had received a 
blow on the skull by the fall of a heavy mallet upon it eleven 
years previously, by which an extensive fracture, involving 
both the parietal and the occipital bones, epilepsy and epileptic 
insanity were developed. I trephined him, removing with the 
assistance of Professor J. T. Darby about four square inches 
of the skull. The paroxysms, both of convulsions and mania, 
ceased, but they returned six months subsequently, and he 
is now in a state of hopeless dementia. 

A boy, eleven years of age, was brought to my clinique 
at the Post-Graduate Medical School, who was subject to 
paroxysms of acute mania, coming on at intervals of a week 
or ten days, during which he was extremely violent and de- 
structive. Upon inquiry and examination it was ascertained 
that, when he was about ^ve years of age, he had fallen down- 
stairs and had struck his head severely. The scar in the 
scalp was still visible, being situated immediately over the 



QQQ DESCRIPTION AND TREATMENT OF INSANITY. 

left frontal eminence. He had occasionally had temporary 
right hemiplegia. I decided to trephine him, and on the 28th 
of February, 1882, I performed the operation before the 
class. There was no fracture, but the dura mater was thick- 
ened at that spot. The result of the operation, as regards 
the insanity, is yet to be seen. At this date (March 2d) he is 
doing well, and is quiet. 

Sunstroke, though not so common a cause of insanity as 
is popularly supposed, produces nevertheless a tolerably large 
number of cases during every summer season, especially in 
this country. Of four hundred and twenty four cases ad- 
mitted into the Illinois Eastern Hospital for the Insane during 
the years 1881 to 1883, thirteen were from this cause ; like 
traumatism, the full action of the factor may be postponed 
for several years. Such, at least, has been my experience. I 
constantly see cases in which pain in the head, inability to 
exert the mind, vertigo, insomnia, and disturbances of the 
sight exist as the consequences of sunstroke or of heat-fever 
for several years, and in which insanity is the ultimate re- 
sult. The form in which it generally appears is that of 
acute mania. Occasionally it ensues immediately on the 
reception of the injury. 

Cerebral Haemorrhage and other diseases of the brain are 
also occasional causes. The influence of epilepsy and chorea 
has already been sufficiently considered. 

Of other diseases, a long list might be made out, each of 
which is recognized as having an occasional causative relation 
to insanity. Among them are phthisis, gout, rheumatism, 
the various fevers, diseases of the heart, intestinal worms, 
and other causes of reflex irritations from the abdominal 
organs, uterine and ovarian disorders, and syphilis. In re- 
gard to this latter, the attempt has been made to make a dis- 
tinct form of mental derangement under the designation of 
syphilitic insanity, but, as I think, without sufficient reason. 
I have never seen anything sufficiently characteristic in the 
insanity following syphilis to warrant such a differentiation. 
It is true that, as regards treatment, there are characteriza- 
tions ; but, if we are to classify the forms of insanity accord- 
ing to the manner in which they should be treated, we would 
do very little toward a scientific nosology, and would, more- 
over, be acting in regard to mental diseases in a way not fol- 
lowed with other affections. 



THE CAUSES OF INSANITY. 



667 



Masturbation and sexual excesses are also to be placed 
among the etiological factors of insanity. In yonng persons, 
their influence is often decidedly manifested. Persons of 
mature age do not appear to incur, except as regards paralysis, 
any noticeable liability to mental derangement, unless they 
are practiced to an inordinate extent, and then they are prob 
ably the symptoms of an already existing mental disease. In 
youth, acute mania, melancholia with stupor, or more gen- 
erally hebephrenia, are produced. Sexual excesses are, how- 
ever, among the most common causes of general paralysis. 
On this point there is no difference of opinion among writers. 
In my own experience I have abundant evidence of its power 
as a factor in producing this disease. 

The occupation followed by the individual may be an ex- 
citing cause of insanity, but it is exceedingly difficult to arrive 
at any conclusion on this point from an examination of the 
tables given in the lunatic asylum reports. The mere fact 
that a greater number of the members of one profession 
than of another are reported is of no value, unless the num- 
bers following each profession in the district from which 
the insane come are also given. This is an almost impossible 
task. 

For instance, the following table is given in the report of 
the Illinois Eastern Hospital for the Insane for 1882 : 

OCCUPATION OF THOSE ADMITTED. 



OCCUPATION. 



Agriculture (proprietors) . . 

Commerce (owners) 

Professions (learned) 

Professions (miscellaneous) 
Day-laborers (unskilled) . . . 

Domestic service 

Needlework 

Trades and handicrafts 

Disreputable 

No occupation 

Unknown 

Totals 



Males. 


Females. 


41 


25 


9 


12 


14 


11 


5 


6 


90 


7 




33 




8 


59 


18 




1 


16 


3 


9 


40 


256 


168 



Total. 



66 

21 

25 
11 
97 
33 

8 
77 

1 
19 
49 



424 



If we judged solely from these data without regard to the 
point referred to, we should be forced to arrive at the conclu- 
sion that " disreputable" occupations are less conducive to 



668 DESCRIPTION AND TREATMENT OF INSANITY. 

insanity than any other, for there is no male patient who owes 
his insanity to such a factor, and only one female patient. 

The influence, however, of certain occupations which are 
in themselves of a specially unsanitary character is more dis- 
tinctly recognized. Thus, workers in lead are liable to insan- 
ity from the absorption of the metal into the system. The 
forms of insanity most apt to be produced are acute mania, 
or some one of the varieties of melancholia. In either case 
there are illusions, hallucinations, and delusions, or the toxic 
influence may result in epileptic seizures ; or these may be 
combined with either of the forms of insanity mentioned. 

Workers in mercury are very apt to suffer from insanity 
as a consequence of the absorption of mercury into the body. 
Several cases of the kind have come under my observation, 
occurring in manufacturers of looking-glasses and workers in 
fire-gilding. The mental symptoms are generally well marked. 
There are hallucinations and delusions, accompanied with a 
high degree of maniacal excitement. As in lead-insanity, 
epileptic convulsions may be associated with the mental de- 
rangement. Other occupations, which require exposure to 
the direct rays of the sun, and consequently induce a liability 
to sunstroke, are also exciting causes of insanity. 

Exposure to morbific emanations from the earth, such as 
malaria, may also conduce to the promotion of insanity. For 
reasons given I cannot admit the existence of any distinctive 
features about the mental derangement caused by malaria, 
but that it does produce aberration of mind is beyond ques- 
tion. 

The influence of malarial poisoning as a cause of insanity 
was pointed out by Sydenham, who refers to a particular 
kind of mania, which, so far from yielding to purgatives and 
blood-letting, is rendered worse by those agencies. It is con- 
sequent upon intermittent fevers which have lasted some 
time, especially those of a quartan type. 

Baillarger ' cites several cases in which intermittent fever 
was followed by insanity, and in which cures were accom- 
plished by the use of antiperiodic remedies. 

Griesinger, 3 in speaking of this cause of insanity, and stat- 

1 " Sur la folie a la suite des fievres intermitteutes," Annates medico-psycho- 
logiques, 1843, t. iii, p. 372. 

2 " Mental Pathology and Therapeutics," New Sydenham Society Transla- 
tion, p. 183. 



THE PROGNOSIS OF INSANITY. 669 

ing that it is not the intermittent fever which induces the 
mental disorder, but the endemic cause of the fever, says that 
the attacks of insanity may take the place of the paroxysm 
of fever. These consist of violent accessions of mania, with 
delirium, and there may be impulses to suicide. Eventually 
these forms may become chronic. 

Again, the insanity may not be developed till after the 
cessation of the paroxysms of intermittent fever, and this he 
says is the most common mode of origin. As he declares : 

"The mental disease frequently continues as a uniform 
persistent chronic affection, and the symptoms of the inter- 
mittent fever are no longer observed." 

Other writers on psychological medicine, and perhaps the 
majority, entirely ignore the relation of cause and effect ex- 
isting between the malarial poison and insanity, and some of 
them, as for instance Dagonet, express the opinion that there 
is no such connection. 

Extensive experience in highly malarial regions in the 
Western and Southern parts of the United States have proved 
to me in the most indubitable manner that malaria is pro- 
ductive of insanity. Sometimes the form is that of acute 
mania ; sometimes morbid impulses of various kinds are ex- 
cited, and, again, morbid fears ; or there may be melancholia, 
simple, with delirium or with stupor, or hypochondriacal or 
hysterical mania, and these may run into dementia. I re- 
ported two or three years since an interesting case of acute 
mania passing into melancholia, which occurred in my expe- 
rience in this city. 1 

Emanations from sewers, dissecting - rooms, slaugMer- 
liouses, and other places where animal and vegetable decom- 
position is going on, are said to be among the causes of in- 
sanity. 



CHAPTER X. 

TEE PROGNOSIS OF INSANITY. 

Two chief questions are to be considered in the discussion 
of the subject of the prognosis of insanity. The first of 

1 '' Insanity of Malarial Origin,'' Xeurological Contributions, No. 1, 1879. 
p. 55. 



070 DESCRIPTION AND TREATMENT OF INSANITY. 

these relates to the life of the patient, the second to his 
mind. 

In regard to the preservation of the life of the subject of 
mental alienation, the prognosis varies, other things being 
equal, according to the type of insanity from which the pa- 
tient suffers. 

Thus, uncomplicated perceptional insanities, whether con- 
sisting of illusions or hallucinations, are very seldom of fatal 
augury. If, however, they are accompanied by physical 
symptoms, indicating profound lesion of the optic thalamus, 
or other parts of the brain, such as paralysis, tremors, destruc- 
tion or marked impairment of the sight, hearing, or other 
sense, severe pains in the head, vertigo, etc., the prognosis 
is much more unfavorable. But, in those cases so frequently 
met with, which depend upon temporary variations in the 
blood-supply of the perceptional ganglia, the prognosis is 
exceedingly favorable, provided that the patient is promptly 
submitted to proper medical treatment. 

Intellectual Insanities. — None of these are of bad prognosis, 
so far as relates to the life of the affected individual. Rela- 
tive to megalomania, under which name he describes in- 
tellectual monomania with exaltation, Dagonet 1 says: "Of 
all the forms of mental alienation, this is perhaps the one 
most compatible with the prolongation of existence. Ex- 
amples of longevity in monomaniacs are not rare in lunatic 
asylums. It appears that the tranquil life which they lead 
there, removed as they are from every cause of excitation, 
and the perfect content which they have with themselves, are 
circumstances which favor the regular action of the organic 
functions." 

Though of the opinion that this is too sweeping a state- 
ment, it is undeniably true that the form of insanity in ques- 
tion is entirely compatible with long life. Intellectual mono- 
mania, with depression, and the depressed form of chronic 
intellectual mania are of more unfavorable prognosis. The 
asthenic effect of the constant terrifying delusions under 
which the patient labors is prejudicial to the normal action 
of the organs of the body. The digestive system is very apt 
to suffer, and hence the basis for intercurrent diseases of the 
stomach, intestines, and liver is laid. Moreover, a depressed 
condition of the mind is not favorable to long life, the powers 

1 Op. cit., p. 276. 



THE PROGNOSIS OF INSANITY. 671 

of resistance to morbific influences being much lessened by its 
action. 

In addition, it must be borne in mind that the tendency to 
suicide, which sometimes exists in these varieties of insanity, 
as well as in intellectual objective morbid impulses, is an ele- 
ment in the prognosis not to be disregarded. 

Reasoning mania and intellectual subjective morbid im- 
pulses are without special significance as regards the life of 
the patient. 

The emotional insanities vary greatly in their tendency to 
a fatal termination, according to the peculiar form of mental 
derangement which exists. Some cases of emotional mono- 
mania tend to suicide, as do also certain instances of emo- 
tional morbid impulses. Others, again, of both these varieties, 
have no such tendency. Aside from the suicidal factor, there 
is nothing in either of these species incompatible with long 
life. 

Simple melancholia is usually not a fatal disorder. Still, 
as in other depressed states of . the mind, the influence upon 
the system generally is bad. 

Melancholia with delirium is a far less hopeful disease. 
Death may take place from exhaustion, from the supervention 
of some other brain-disease, from an intercurrent affection, or 
from suicide. 

Melancholia with stupor, though scarcely having as bad a 
prognosis as the delirious form of melancholia, is, neverthe- 
less, a disease which tends to shorten life, either directly or by 
gradually leading to secondary diseases. The same is true 
of hypochondriacal melancholia. 

In hysterical mania the prognosis as regards life is good. 

There is nothing about epidemic insanity which specially 
tends to death, unless the form be one in which great mental 
depression or suicidal tendencies prevail. 

Volitional insanities, except in regard to the act of suicide, 
which may be perpetrated as a volitional morbid impulse, 
are entirely compatible with long life. 

Of the compound insanities, the prognosis as regards life 
in acute mania is fairly good. Death, however, may take 
place from exhaustion, from the supervention of some other 
disease, or from suicide. Periodical insanity may also re- 
sult fatally from like causes, as may likewise circular in- 
sanity, but the prognosis in both these forms is better than 



672 DESCRIPTION AND TREATMENT OF INSANITY. 

in acute mania. Hebephrenia and Jcatatonia are of still better 
prognosis, but occasionally they terminate fatally from ex- 
haustion or from some intercurrent affection. 

None of the dementias of this group are of themselves 
specially detrimental to life. The condition of mere vegeta- 
tive existence to which some dements reach, in which the 
"wear and tear" of the body is at its minimum, allows of 
long life. Death, when it does come, often arrives with sud- 
denness, and life is abolished during the night, without any 
one being the wiser, till morning reveals a corpse instead of a 
living body. 

The remaining affection of this group, general paralysis, 
is the most uniformly fatal of all forms of insanity. I have 
never known a case to recover. A few instances of apparent 
recovery have been reported, but many authors doubt their 
authenticity. Death usually occurs within three years, and 
frequently within a few months. Occasionally life is pro- 
longed to five or six years, or even, in very rare instances, to 
double this period. 

Of the constitutional insanities, puerperal and choreic insani- 
ty are of very favorable prognosis. If death occurs in either 
of these, it is from secondary causes. As to epileptic insanity, 
the prognosis is not so good, though life may be prolonged 
for a considerable period. Pellagrous insanity is of bad 
prognosis as regards the life of the affected person. The con- 
stitutional disease is rarely if ever cured, and eventually the 
patient succumbs to it. In addition, the strong tendency to 
suicide, which is so prominent a feature of the mental derange- 
ment accompanying pellagra, adds greatly to the liability to 
a fatal termination. 

The second question in regard to the prognosis of insanity 
relates to the restoration of the insane person to a normal 
condition of mind. 

In perceptional insanities the prognosis is usually good if 
there are no disturbing complications, such as those referred 
to in the early part of this chapter, and if they have arisen 
as the consequence of some temporary variation in the nor- 
mal amount of the intra-cranial blood. The readiness with 
which they yield to treatment, whether medicinal or hygienic, 
under these circumstances, or even spontaneously disappear, 
are matters with which most physicians are acquainted. 

Of the intellectual insanities the prognosis in intellectual 



THE PKOGNOSIS OF INSANITY. 673 

monomania with exaltation is fairly good : about half the 
cases recover under suitable treatment, the remainder dying, 
or, what is much more likely to be the termination, degenerat- 
ing into dementia. Occasionally the original symptoms con- 
tinue unchanged for many years. 

In intellectual monomania, with depression, the prognosis 
is not so good, about one third only recovering their normal 
reasoning powers. Many cases are transformed into some 
form of melancholia, while others again terminate in demen- 
tia. The prognosis is better when the affected individuals 
are young, of good constitutions, and of temperate modes 
of life. 

In both these forms the existence of a strong hereditary 
tendency to insanity renders the prognosis more grave. 

Chronic intellectual mania rarely terminates in the recov 
ery of the normal mental condition of the patient, the ten- 
dency being toward dementia as the patient advances in years. 

Reasoning mania is quite a hopeless condition. In this 
affection there are original defects of cerebral organization 
which cannot be overcome. Under the most favorable cir- 
cumstances there may be for a time some improvement in the 
mental condition of the individual, but this is only temporary, 
as relapses are very certain to occur. 

Intellectual subjective morbid impulses are not ordinarily 
of serious import, unless there is a marked degree of heredi- 
tary tendency to insanity. Under proper medical and hygi- 
enic treatment they usually disappear. 

Intellectual objective morbid impulses, though not of so 
favorable a prognosis as the last-mentioned form, do not gen- 
erally resist suitable treatment. 

The emotional insanities are very often the result of inherit- 
ance or of a strong development of what has been called the 
"insane temperament." The prognosis is, therefore, in sev- 
eral of the forms unfavorable. In emotional monomania and 
emotional morbid impulses the patient, if young and favor- 
ably circumstanced, not infrequently recovers under medical 
and hygienic treatment. All forms of melancholia, espe- 
cially the hypochondriacal variety, are of rather unfavorable 
though not hopeless prognosis. As regards simple melan- 
cholia, however, the prognosis is somewhat better than that 
of the others, but the liability to relapses is great. Hysterical 
mania is of good prognosis, so far as any individual attack is 

43 



674 DESCRIPTION AND TREATMENT OF INSANITY. 

concerned, but here again the tendency to recurrences is 
strong. Epidemic insanity, such as is met with at the pres- 
ent day, is generally curable by sound moral and hygienic 
treatment. 

The volitional insanities are often the results of original 
defects of organization, and in such cases are quite incurable. 
Some instances, however, are acquired through remediable 
causes, and such are of hopeful augury. 

Of the componnd insanities, acute mania terminates in 
recovery in about one third of the cases, the remainder either 
dying or passing into secondary dementia. Periodical in- 
sanity often terminates in recovery, if advantage be taken of 
the intermission to improve the mental hygiene of the pa- 
tient. It rarely terminates in spontaneous cure. Hebephrenia 
is generally of quite hopeless prognosis, and that of circular 
insanity — I have seen one case recover — is not much better. 
On the other hand, in Catatonia, recovery may often be ex- 
pected if there be no unfavorable complications. 

Primary dementia is not, unless there is a strong heredi- 
tary tendency to insanity, a disease of a very bad prognosis. 
Secondary dementia and senile dementia are scarcely curable. 
In senile dementia, however, it is sometimes the case that the 
disease is produced in a comparatively young person by some 
external cause, in which case a cure may occasionally be 
effected. 

In general paralysis the remissions which occur are some- 
times so long as to excite the idea of a cure, but such cases 
are exceedingly rare, and death is, as we have seen, the ter- 
mination to be expected. 

Of the constitutional insanities, epileptic insanity and pel- 
lagrous insanity are quite incurable in the great majority 
of cases. On the other hand, puerperal and choreic insanity 
usually terminate in recovery. A few general observations 
relative to the prognosis in insanity may well conclude this 
chapter. 

In all cases of insanity there is a certain liability to re- 
lapses, and hence the mere fact of recovery in any individual 
attack affords no security against the recurrence of the dis- 
ease, either in its original or in some other form. Thus it is 
stated by Dr. Ray, 1 in a paper read before the Philadelphia 

1 "Recoveries from Mental Disease," The Alienist and Neurologist, April, 
1880, p. 136. 



THE PROGNOSIS OF INSANITY. 675 

College of Physicians, that at the Pennsylvania Hospital for 
the Insane, u one man was admitted on the twenty-second at- 
tack, and one woman on the thirty- third ; six men and six 
women on the tenth attack ; ninety -four persons on the fifth 
attack, and one hundred and seventy-two on the fourth."- Dr. 
Ray then quotes Dr. Kirkbride as follows : 

"When an individual suffering from insanity is relieved 
from all indications of mental unsoundness, returns to his 
home and family without any developed eccentricity, resumes 
his ordinary relations to society, attends to his business with 
his usual ability and intelligence for a year, or even a much 
less period, we have no hesitation in recording such a case as 
4 cured,' without any reference to the future, about which we 
can know nothing. We have no power to insure any case, or 
to say that there will never be another attack. We have no 
right to assert that a combination of circumstances like that 
which produced the first may not cause another ; that ill- 
health, and commercial revolutions, and family sorrows, and 
the many other causes that may have originally developed 
the disorder, may not again bring on a return of the same 
symptoms, just as they may produce them in one who has 
never had an attack of the kind. Five thousand six hundred 
and ninety -five of those received here never had an attack be- 
fore. Whatever induced the disease in them certainly may 
induce it in those who have already suffered from the same 
malady, for we cannot expect one attack of insanity to act as 
a prophylactic, and, like measles or small-pox, to give im- 
munity for the future. But this new attack is no evidence 
that the patient was not cured of the previous one. If the 
patient, then, is well in the sense in which he is considered 
well from an attack of typhoid fever, or dysentery, or rheu- 
matism, or a score of other maladies, when another attack is 
developed, it is as much a new case, and the recovery is a cure, 
as much as it would be if he suffered from any other form of 
illness, and it ought to be so recorded." 

But, with all due respect for the eminent Superintendent 
of the Pennsylvania Hospital for the Insane, it appears to me 
that this is not the proper way of putting the question. No 
one contends that insanity acts as a prophylactic against a 
second attack, but it is asserted that the existence of one at- 
tack renders the individual more prone to another than he 
would be if he had never had the first. Would Dr. Kirk- 



676 DESCRIPTION AND TREATMENT OF INSANITY. 

bride hold that his "five thousand six hundred and ninety- 
five " virgin cases, if all cured and discharged from the asylum, 
are not more liable to become insane than "five thousand six 
hundred and ninety-five " persons who have never been in- 
sane? Is it not true that these "five thousand six hundred 
and ninety-five " cured lunatics are more liable to second at- 
tacks of mental derangement than the same number of per- 
sons who have had "typhoid fever, or dysentery, or rheuma- 
tism, or a score of other maladies"? Was there ever a man 
who had twenty-two attacks of typhoid fever, or a woman 
thirty- three attacks of dysentery ? 

The fact is, that one attack of insanity predisposes the pa- 
tient to another. The predisposition may never be required 
to act, but the subject of it is always in danger. In some 
forms this predisposition is not great ; in others it probably 
will be influential in producing another accession, either from 
the operation of strong exciting causes or of others scarcely 
perceptible — factors which a person with a flawless clinical 
history would be able to resist.. 

But there is another point. The statistics of insanity are 
almost entirely derived from- the records of lunatic asy- 
lums. For the future, owing to the growing disposition 
among physicians to treat at home many cases of insanity 
which formerly would have been sent to the asylum, this 
state of things is likely to be changed. The fact, however, 
has led to a curious result. 

Dr. Pliny Earle, 1 Superintendent of the Northampton 
(Massachusetts) Hospital for the Insane, perceiving that the 
proportion of cured cases of insanity is less now than it was 
fifty years ago, inquired into the personal histories of twenty- 
five cases that were discharged as cured from the Worcester 
Asylum in Massachusetts. Each case was sought out, and the 
history before and after the discharge as "cured" was ascer- 
tained with all desirable minuteness. The conclusions estab- 
lished were as follow : 

"1. The twenty-five persons were discharged recovered 
from the hospital forty-eight times, contributing forty-eight 
recoveries to the statistics of insanity. 

' ' 2. The five persons who died in the hospital had been 

1 " Subsequent History of Twenty-five Persons reported recovered from 
Insanity in 1843," and " The Curability of Insanity vs. Recoveries from Mental 
Disease," The Alienist and Neurologist, January, 1880, pp. 64, 82. 



THE PROGNOSIS OF INSANITY. 677 

discharged recovered fifteen times, an average of three recov- 
eries to each person. 

"3. Of all the hitherto published representations of the 
curability of insanity, the most unfavorable are those of Dr. 
Thurnan, who based a general formula upon the actual results 
in 244 persons (treated at the York, England, retreat) whose 
history he had traced until death. 

" 'In round numbers, then,' said he, 'of ten persons at- 
tacked with insanity, live recover and iive die sooner or later 
during the attack. Of the five who recover, not more than 
two remain well during the rest of their lives ; the other three 
sustain subsequent attacks, during which at least two of them 
die.' " 

Dr. Earle states other points of interest, for which I must 
refer the reader to the original paper. He then says : 

" As so many [fifteen] are still living, it is impossible to 
say what will be the final result in regard to the number 
dying insane. But already iive have died insane at the hos- 
pitals, and two have died insane at home, making a total of 
seven. Two others are at almshouses, both having for a long 
period been incurably insane- (they will undoubtedly die so), 
and one has died at home, • who was never well (sane) but a 
few months at a time.' " 

And Dr. Earle adds, "Can our statisticians, philanthro- 
pists, and statesmen, longer be surprised that the hospitals 
do not put a stop to insanity % " 

But, in the second paper in the same journal to which I 
have referred, Dr. Earle gives some data which are still more 
remarkable, and which are as follow : 

"The total recoveries of the five persons at Frankford are 
fifty-two. 

"At the Hartford Retreat, five persons have been reported 
recovered, as follow : one, fourteen times ; another, thirteen ; 
a third, nine ; a fourth, nine ; and a fifth, nine. Total recov- 
eries of the five persons, fifty-four. 

"At the Bloomingdale Asylum, as long ago as the year 
1845, five men had been reported as recovered : one of them, 
seventeen times ; another, thirteen ; a third, twelve ; a fourth, 
eleven ; and a fifth, ten. Total recoveries of the five, fifty- 
nine. 

"At the same institution, at the same time, five women 
have been reported recovered : one, twenty times [in a note 



C78 DESCRIPTION AND TREATMENT OF INSANITY. 

it is stated that this woman has since increased her recoveries 
to forty-six] ; another, nineteen ; the third, seventeen ; the 
fourth, thirteen ; and the fifth, twelve. Total recoveries of 
the five, eighty -one [one hundred and seven]. 

"At the Worcester Hospital, five men have been discharged 
recovered : one of them, fourteen times ; another, fourteen ; 
the third, twelve ; the fourth, nine ; and the fifth, nine. Total 
recoveries of the five, fifty-eight. 

" At the same institution, five women have been discharged 
recovered : one of them, twenty-two times ; another, sixteen ; 
the third, fifteen ; the fourth, fourteen ; and the fifth, eleven. 
Total recoveries of the five, seventy -eight. 

"Uniting these two sex-groups of Worcester patients, and 
taking the highest five of them, one recovered twenty-two 
times ; another, sixteen ; the third, fifteen ; the fourth, four- 
teen ; and the fifth, fourteen. Total recoveries of the five, 
eighty-one. 

" At the New Hampshire Asylum at Concord, even among 
the twenty-seven patients discharged recovered in the official 
year 1878-79, there were five the number of whose recoveries 
has been : one of them, thirty-six times ; another, ten ; the 
third, nine ; the fourth, five ; and the fifth, three. Total re- 
coveries of the fiN^ sixty-three. The number of recoveries 
of these five persons is larger by eleven than that at Frank- 
ford. But, of all the patients ever treated at Concord, the 
highest five were as follow : one recovered thirty-seven times ; 
another, sixteen ; the third, eleven ; the fourth, ten ; and the 
fifth, ten. Total recoveries of the five, eighty -f our. v 

Dr. Earle then goes on to point out that, at the Concord 
Asylum, ten persons recovered a total of one hundred and 
twenty times, or an average of twelve recoveries to each. 
At Bloomingdale ten patients recovered one hundred and 
twenty-two times, and at Worcester one hundred and thirty- 
six times, an average of over thirteen recoveries to each 
patient. 

These data, by an alienist who confessedly stands at the 
very head of the insane asylum superintendents, are sufficient 
to destroy the little vestige of confidence existing in regard to 
asylum statistics. Well might a member of the New Eng- 
land Psychological Association, at the meeting before which 
Dr. Earle's paper 1 was read, say that "he thought something 
1 The Alienist and Neurologist, April, 1880, p. 258. 



THE PROGNOSIS OF INSANITY. 679 

should be said to counteract the evil effect which such a 
showing would have upon the public." 

But what can be said % Dr. Ray, who, in previous papers 
published originally many years ago, ' had investigated some 
of the points connected with asylum statistics, in a paper 3 
from which I have already quoted, and which was intended 
as in some measure an answer to Dr. Earle, concludes : 

" I. Those qualities of temperament which lead men to 
unduly magnify their achievements are as common at one 
time as another. 

"II. The practice of reporting cases instead of persons 
has not been confined to any particular period, and, therefore, 
while it may vitiate our estimate of the curability of insanity, 
it cannot make the proportion of recoveries larger or smaller 
at one period than at another. 

" III. Cases marked by high excitement entered our hos- 
pitals in a larger proportion to those of an opposite character 
fifty years ago than they do now. 

"IV. Under the influence of highly civilized life, the con- 
servative powers of the constitution have somewhat depre- 
ciated, and to that extent have impaired the curability of 
insanity. 

"V. During the last fifty years, cerebral affections, in 
which insanity is only an incident, have been steadily increas- 
ing, and thus diminishing the proportion of recoveries." 

This does not make it any better for the statistics, which, 
according to Dr. Ray, are as bad now as they have ever been. 

It really looks as though cases of circular insanity and of 
periodical mania are reported as cured every time the patient 
has an intermission. Just as though a person with a tertian 
ague should be reported as cured fifteen times in one month, 
although he has had fifteen paroxysms. 

But there is one factor to which in the body of his paper 
Dr. Ray alludes, and that is the appearance of general paral- 
ysis within little more than the last thirty years. Previous to 
that time this fatal disease was unknown to American physi- 
cians. It did not exist in the country, for "Dr. Bell, who 
first observed it in Europe in 1845 [and who certainly was ac- 

lu Statistics of Insanity," and "Doubtful Recoveries," "Contributions to 
Mental Pathology," Boston, 1873, pp. 66, 121. 

v a "Recoveries from Mental Disease," The Alienist and Neurologist, April, 
1880, p. 141^, 



080 DESCRIPTION AND TREATMENT OF INSANITY. 

quainted with, the descriptions of it made twenty years pre- 
viously by Calmeil and others], satisfied himself after the 
most thorough examination of the case-books of the McLean 
Asylum, that up to that period no instance of it had been 
observed in that institution, though since then it has been 
common enough." 

The development of this uniformly fatal disease within 
the time mentioned has, of course, had an influence in ren- 
dering the mortality and the incurable cases greater in the 
asylums than at former periods. 

\But, after all, the prognosis of insanity cannot, even under 
a system of entirely reliable statistics, be deduced from the 
records of lunatic asylums, and this for the reason that the 
most curable forms are not sent to asylums. What physician, 
for instance, would think of sending to such an institution a 
patient who had nothing but a hallucination of sight or hear- 
ing under certain circumstances, or one with intellectual sub- 
jective morbid impulses, or one with morbid fears (emotional 
monomania), or with most of the forms of emotional morbid 
impulses, or many of the cases of hypochondria, or of hysteri- 
cal mania, or of volitional morbid impulses, or of paralysis 
of the will, or of puerperal or choreic insanity ? 

The subjects of most of these forms are at all times com- 
petent to attend to their ordinary business, and they do at- 
tend to it. Nevertheless, their minds are deranged. Such 
cases are largely of favorable prognosis, and, as they do not 
enter asylums, these latter are deprived of the benefit of 
counting cases that would legitimately improve their statis- 
tics ; whereas they receive a large proportion of the chronic, 
the very severe, and the incurable cases. 

The prognosis of insanity, as deduced from private prac- 
tice, is, therefore, taking all these points into consideration, a 
very different thing, more reliable and more hopeful than that 
of the asylums generally. 



THE DIAGNOSIS OF INSANITY. 681 

CHAPTEK XL 

. THE DIAGNOSIS OF INSANITY. 

There is no point connected with the subject of insanity 
which is of more importance than that of its diagnosis. On 
the answer which the physician may give to the question, 
" Is the person insane % " depends often not only the liberty of 
the individual, his right to his property, his ability to make 
a will or a contract, but even life itself. Heretofore physi- 
cians have frequently allowed legislative bodies and courts to 
tell them what insanity is. They have confounded insanity 
with irresponsibility, whereas many of the insane are wholly 
or in part accountable for their acts, while many who are re- 
garded as sane are not accountable. 

Of course it is entirely right and proper that there should 
be an unyielding line to separate legal sanity from legal in- 
sanity, and no better one than that based upon a knowledge 
of the nature and consequences of an act, and that it is or is 
not a violation of law, can be devised. Any one possessed of 
this knowledge is legally sane, and legally responsible for his 
acts. 

But when it comes to the science of the matter the thing 
is very different. As I have defined insanity in a previous 
chapter, it consists of "a manifestation of disease of the 
brain, characterized by a general or partial derangement of 
one or more faculties of the mind, and in which, while con- 
sciousness is not abolished, mental freedom is weakened, per- 
verted, or destroyed." An intellectual subjective morbid im- 
pulse, by which a person — as, for instance, the young lady 
whose case is given on page 383 — is compelled to repeat men- 
tally over and over again certain words, or who, like Professor 
Ball's patient (page 388), could not get rid of a ridiculous 
idea, is certainly insanity. ' 6 One or more faculties of the 
mind" are deranged, and " mental freedom is weakened, per- 
verted, or destroyed" ; but a person the subject of such de- 
rangement is not insane according to the legal standard, and 
ought to be regarded as fully responsible for any crime he or 
she may commit. 

Again, take the instance of the patient whose case is de- 
tailed on page 527 as an instance of paralysis of the will. 
Such a person clearly comes within the definition of insanity, 



G82 DESCRIPTION AND TREATMENT OF INSANITY. 

and yet ifc would be absurd to regard a person as irresponsible 
for a violation of law, simply because lie is unable to deter- 
mine which shoe to remove first. 

In former times the idea of a lunatic was very different 
among physicians, lawyers, and laymen, from what it is now. 
There was entire uniformity on the subject, for no one was 
considered insane who was not a raving maniac, a person who 
did not know the nature and consequences of his acts. But 
science has advanced more rapidly than law, and many vari- 
eties of insanity are now known to exist which, when Black- 
stone wrote, were not regarded as departures from the ordi- 
nary standard of sound mental health. We know that the 
smallest deviation from the normal state of any organ of the 
body impairs to some extent the functions of that organ, and 
consequently deranges the physical health of the individual. 
A small fraction of a grain of tartarized antimony taken into 
the stomach excites nausea, and perceptibly disturbs the sys- 
tem generally. The hundredth of a grain of atropia dropped 
into the eye destroys for hours the clearness of vision. In 
both of these instances there is, for the time being, bodily dis- 
ease. Why, then, should the brain form any exception to the 
other organs, and why should not slight deviations from its 
normal mode of action be regarded as instances of mental 
disease ? They are just as much evidences of brain disorder 
as pus in the urine is evidence of disorder of some portion 
of the genito-urinary system. 

It is from this stand-point — the purely medical one — irre- 
spective of what parliaments and legislatures and courts 
have decided, that the subject of the diagnosis of insanity 
will be considered in this work. The medico-legal relations 
of mental derangement belong entirely to the domain of 
medical jurisprudence. 

In beginning the examination of a person alleged to be 
insane, the full clinical history should, if possible, be ob- 
tained, and no point in his antecedents is altogether unworthy 
of notice. Inquiry should especially be made relative to the 
matter of hereditary tendency, the diseases the patient may 
have had, especially in regard to those of the brain and ner- 
vous system generally. The fact of a previous attack of in- 
sanity is an important point. 

Then the occupation, habits, mode of life, natural charac- 
ter, and disposition should be ascertained, and all possible 



THE DIAGNOSIS OF INSANITY. 683 

data in regard to the existing accession, the time of its occur- 
rence, the premonitory symptoms, its mode of development, 
and present symptoms, especially as to sleep, should be de- 
rived from some sensible person who has been in intimate re- 
lations with the patient. 

Then the subject himself should be carefully examined. 
Efforts should be made to gain his confidence, and such ques- 
tions should be put to him — guardedly, if necessary — as the 
previous information may suggest as most likely to cause him 
to disclose the present working of his mind. If the patient 
be an educated person, the physician will require not only a 
knowledge of medicine, but an acquaintance with the philos- 
ophy of the human mind, in order to conduct his examination 
with skill, and yet at the same time to acquire a proper de- 
gree of ascendency over the person whose mental status he 
proposes to investigate. Many lunatics are shrewd, intelli- 
gent, and ready to take advantage of any one whose in- 
feriority to themselves they think they detect. The more 
extensive and thorough is the general knowledge of the phy- 
sician, the more readily will he obtain the influence over the 
patient which is so necessary to a complete examination. It 
is usually no very difficult task to get a lunatic to speak of 
his delusions, but sometimes he conceals them with a degree 
of obstinacy difficult to overcome. Of course, in many cases 
there is not the slightest difficulty in determining the insanity 
of a person alleged to be of unsound mind. His restlessness, 
gestures, play of his countenance, incoherence, mental excite- 
ment, extreme loquaciousness, betray him at once, and a 
lengthened examination is not necessary. 

But in more doubtful cases, the perceptions, the emotions, 
the intellect, and the will, should all be examined into with 
thoroughness and exactness. The existence or non-existence 
of illusions or hallucinations ; the sluggishness, hyper-activ- 
ity, or incongruousness of the feelings ; the degree of intelli- 
gence, the power of the judgment, and especially of the mem- 
ory, should be tested ; the ability to sustain a continuous line 
of thought should be ascertained ; his appreciation of his sur- 
roundings, of his position in life, of his means, his where- 
abouts, the object of his visit, and the character of the opin- 
ions he expresses and of the feelings he reveals, should be the 
subjects of inquiry. In short, nothing should be omitted 
which may be necessary to make the physician acquainted 



CS4 DESCRIPTION AND TREATMENT OF INSANITY. 

with the previous mental organization and present state of 
mind of the individual he is examining. 

By an inspection of the body and its actions a great deal 
of valuable information can be obtained, and it is all the more 
useful because it is often of such a character as cannot be con- 
cealed or assumed. 

First of all comes the countenance. Here the expression, 
as regards joy, or sadness, or stolidity, the play of the facial 
muscles, the movements of the eyes, the motions of the lips, 
the stability of the tongue when it is protruded, the presence 
or absence of fibrillary contractions of its muscles, the condi- 
tion of the pupils as regards motility to the stimulus of light, 
their permanent condition of contraction or dilatation, their 
equality or inequality, the presence or absence of ptosis or di- 
plopia, are all matters of importance. 

Then the function of speech is capable of affording valu- 
able indications. The character of the articulation, the ability 
to pronounce words with lingual or labial consonants with 
ease and accuracy, the degree of effort which it is necessary 
to make in order to articulate difficult words, the misplacing 
of words in a sentence, the omission of their final syllables, 
their clumsy pronunciation, the slurring over of words or syl- 
lables, the forgetfulness of words, are points in regard to 
which the examination cannot be too minute. 

The gestures and movements generally which the patient 
may make, the degree of mobility, the sluggish condition of 
the body, the presence or absence of cataleptic phenomena, 
the actions as regards propriety and decency, the presence 
or absence of tremor or paralysis of any part of the body, the 
degree of readiness with which he responds to directions or 
requests to rise or sit down, to walk or to cease walking, or to 
put out his tongue, the position in which he holds his head — 
whether inclined forward in an attitude of weakness, indicat- 
ing dementia or general paralysis, or thrown back in response 
to emotions of pride or greatness — are all to be observed. 

The gestures which the feelings or passions of the patient 
may prompt him to make are always indications of great im- 
portance as showing the amount of power which he possesses 
over the expression of his passions. A man who exhibits 
every passing feeling which he may have, and exhibits it as 
he may do by an exaggerated or misplaced or incongruous 
gesture or action, affords some evidence of mental aberration. 



THE DIAGNOSIS OF INSANITY. 685 

The woman with erotomania puts on languishing airs, and 
makes amorous advances to any man she may meet. The 
subject of religious monomania falls down on his knees and 
prays without regard to the fitness of the occasion or the at- 
tendant circumstances. The general paralytic, with his de- 
lusions of greatness, speaks in a loud tone, struts about the 
room elevated to his extreme height, strikes his inflated chest 
to exhibit his strength and endurance, shows his muscular de- 
velopment, etc. The melancholic groans and sobs, wrings his 
hands, hides his face in order to conceal his tears, refuses to 
speak, or answers slowly in monosyllables and with evident 
reluctance. 

Relative to the state of the viscera, the most important 
points are connected with the stomach and bowels and blad- 
der. Dyspepsia, want of appetite, constipation, are often pres- 
ent. There may be paralysis of the bladder or its sphinc- 
ter, or both. In connection with hypochondria, there may 
be various abnormal sensations in the thoracic, abdominal, 
or pelvic viscera, to which the attention of the patient is con- 
stantly directed, and to which he is anxious to attract the 
notice of the physician. The condition of the spinal cord 
and the evidences of its derangement which are supplied by 
the state of sensibility and motility should be carefully inves- 
tigated. 

The physician may be required to investigate a case in 
which it is suspected that the individual is feigning insanity. 
Persons have done this so effectually that they have succeeded 
in imposing on the superintendents of lunatic asylums, and in 
being treated as raving maniacs, the object being to observe 
the system upon which the institutions were managed. A 
very little intelligence and acquaintance with the phenomena 
of insanity will enable an impostor to deceive the ordinary 
average superintendent, who asks a few questions, and, get- 
ting incoherent answers and observing an agitated demeanor, 
jumps at the willing conclusion that he has a lunatic before 
him. There are superintendents and other medical officers of 
asylums, however, who, not boasting that they have never 
made mistakes, are nevertheless difficult persons to deceive by 
so transparent a fraud as that to which I have alluded, though 
no one, no matter how skilful an alienist he may be, is beyond 
the point of being imposed upon for a short time by persons 
assuming to have certain forms of mental derangement. An 



686 DESCRIPTION AND TREATMENT OF INSANITY. 

individual may tell his physician, for instance, that he has a 
pain in his great-toe, and will apparently walk with difficulty, 
and it will be impossible for his medical adviser to determine 
at the moment whether he has or not. But if he has the op- 
portunity for observation, and he has reasons for suspecting 
that the patient may have an object in attempting to deceive 
him, he will probably find out very shortly whether or not 
he is telling the truth. He will watch him when the man 
thinks he is not observed, and will ascertain whether or not 
he walks lame ; he will find out whether or not his prescrip- 
tions have been used, or his directions not to walk observed. 
It is almost certain that in a short time any fraud would, 
under these circumstances, be detected. 
•Y So it is with many forms of fraudulent insanity. The 
existence of illusions and hallucinations may be feigned, as 
may also all forms of monomania and morbid impulses, all 
forms of volitional insanity, and several of those of emotional 
and compound insanities, and the detection of the imposture 
would be difficult if not impossible at once. If a man says 
he believes he is the Governor of the State of New York, and 
acts in accordance with his belief within the limits of his in- 
telligence and power, who can say that he does not believe 
what he says he does ? If opportunity be afforded for watch- 
ing him, and he is assuming a delusion which he does not en- 
tertain, it is quite certain that he will by some incongruous 
or inconsistent speech or act betray himself. And so of all 
such fraudulent assumptions, the lack of uniformity and con- 
sistency will inevitably be exhibited in time. 

If the variety of insanity feigned be of some form charac- 
terized by excitement of mind and body, as acute mania, for 
instance, the performer is almost certain to overact his part. 
Moreover, a little observation will catch him at times when 
he does not know that he is watched, and questions put to 
him suddenly will often take him unawares and receive a ra- 
tional answer. Waking him suddenly will often so surprise 
his mind that for an instant he forgets his role. 

And time here, as in the other instances cited, will leave 
no doubt as to the real state of the case. No man can con- 
sistently play the part of a lunatic for any considerable period ; 
exposure is certain to result. For these reasons, in all cases 
in which there is some powerful reason which may be an in- 
centive to the assumption of insanity, the physician, if he has 



THE DIAGNOSIS OF INSANITY. 687 

any doubt in regard to the matter, after a first examination, 
should decline to express a definite opinion unless additional 
opportunities at long intervals be afforded him for making 
other observations. It often happens that insanity is feigned 
by persons accused of crime. In such cases there is, of 
course, the strongest incentive to deceive, but it is believed 
that no case of the kind can be successfully imposed upon 
the skilled physician with time and opportunity at his com- 
mand. 1 

For the purpose of accomplishing certain objects, lunatics 
sometimes feign another form of insanity from that with 
which they are affected. This is especially apt to be the case 
with chronic lunatics, or those who possess original defects of 
cerebral organization, such as the reasoning maniacs. There is 
reason for believing that Guiteau, who belonged to this class, 
feigned a different type of mental aberration from that with 
which he was born. 

In regard to the special varieties of insanity embraced in 
the classification forming the basis of the present work, it is 
scarcely possible for errors of diagnosis to be made in the 
differentiation of one from the other, if the phenomena of 
such be carefully studied, except as regards a very few of the 
forms. These I propose now to consider in their diagnostic 
relations : 

It is possible to confound intellectual monomania of tlie 
exalted form with general paralysis, but a consideration of 
the facts that the physical symptoms of the latter disease 
are wanting in the other will prevent any misapprehension. 
Attention, therefore, should not be concentrated on the men- 
tal phenomena, but the pupil, the motility of the face, the 
articulation, the ophthalmoscopic appearances, the presence 
or absence of the sense of smell, the gait, should all be the 
subjects of minute examination. 

Intellectual monomania with depression is liable to be 
confounded with simple melancholia, but the presence of de- 
lusions in the first named will suffice to make the diagnosis 
clear. Moreover, the facts that no matter of how logically 

1 The full consideration of this question belongs more to the department of 
medical jurisprudence than to a work of the character of the present. The 
reader is, therefore, referred to the treatises on that branch of science for more 
complete information on the subject. The works of Wharton and Stille, Legrand 
du Saulle, and the " Etude medico-legale sur la simulation de la folie," par 
Laurent, Paris, 1866, will give all requisite information. 



688 DESCRIPTION AND TREATMENT OF INSANITY. 

depressing a character the delusions may be, the effect upon 
the emotions of the patient is not as intense as it should be if 
they were true, will suffice to distinguish it from all forms of 
melancholia. The patient seems as though he did not him- 
self fully believe in the truth of his delusions. 

In chronic intellectual mania there are also delusions, but 
they are variable to a greater or less extent, and the delirium 
is usually of a more marked form. 

In reasoning mania the physician will often require all 
his acumen and knowledge, as well as time and further oppor- 
tunities for observation, before he can venture to pronounce 
a decided opinion. Here the clinical history of the case is 
of especial advantage. 

Hysterical mania presents very few difficulties, if a full 
clinical history can be obtained. The patients, however, 
sometimes exercise all their powers of control in order to 
conceal abnormal manifestations, and again, feign symptoms 
which they do not possess. They are, nevertheless, easily 
thrown off their guard. 

In the diagnosis of periodical insanity and circular in- 
sanity, time is required to elucidate the character of the men- 
tal aberration. Here, again, data in regard to previous acces- 
sions will be of great value. 

Primary dementia may be mistaken for general paralysis, 
and in the earliest stages it may for a time be impossible to 
make the discrimination between the two conditions. But 
this uncertainty cannot be of long duration, for the symp- 
toms peculiar to either disease are sharp enough to enable a 
differential diagnosis to be made. It is scarcely possible to 
confound general paralysis with any other form of insanity, 
but it may be under certain circumstances mistaken for other 
nervous affections not characterized by mental derangement. 

Thus, without very careful inquiry and examination, it 
might be confounded with certain cases of cerebral Timmor- 
rhage, in which there are mental enf eeblement, difficulty of ar- 
ticulation, and inequality of the pupils, as well as more or less 
paralysis. But the difference in the mental symptoms as well 
as the mode of onset will enable the physician to diagnosticate 
the two conditions. There is, however, in old cases of cere- 
bral haemorrhage sometimes a condition of dementia combined 
with paralysis very difficult to distinguish from the latter 
stage of general paralysis. 



THE DIAGNOSIS OF INSANITY. 689 

Chronic alcoholic intoxication, with its tremor, paresis, 
and mental derangement, presents some features analogous 
with those of general paralysis ; but the prompt disappear- 
ance of the phenomena in the former affection as soon as 
the alcoholic potations are suspended soon indicates the dif- 
ference. 

Progressive muscular atrophy, when it affects the mus- 
cles of the face and tongue, presents at first sight phenomena 
very much like those of general paralysis. Moreover, the 
troubles of articulation in ths two affections are very similar. 
In an intermission of general paralysis, and in a case without 
clinical history, and in the early stage, a mistake might 
readily be made. A little time, however, will serve to rectify 
the error ; and, when general paralysis is in its active state, a 
failure to diagnosticate the two conditions is scarcely pos- 
sible. The presence of mental symptoms in the one and their 
absence in the other, and the oculo-pupillary phenomena of 
general paralysis, will be sufficient for the purpose. 

In glosso-ldbio-laryngeal paralysis, under like circum- 
stances, a mistake may equally readily be made, or general 
paralysis with a remission or intermission of the mental 
symptoms may be mistaken for the former disease. In a case 
which came to my clinique at the New York Post-Graduate 
Medical School, and which was said to be one of general 
paralysis, I could detect no mental aberration and no oculo- 
pupillary symptoms. There were fibrillary movements in the 
tongue, defective articulation, and the peculiar tremulous 
movements of the lips met with in both diseases. I hesitated, 
therefore, to pronounce it one of general paralysis. But two 
or three days afterward, when the patient returned, there was 
not only inequality of the pupils in a marked degree but 
decided mental exaltation. Since then it has several times 
happened that the pupils were perfectly equal in size, and 
reacted normally to light. 

A few words in conclusion are perhaps necessary in regard 
to the distinction which sometimes has to be drawn between 
the condition known as heat of passion and certain states 
known as transitory mania, but which have been described 
in this work under the heads of morbid impulses of various 
kinds and epileptic insanity. 

An act performed in the heat of passion is one prompted 
by an emotion which for the moment controls the will, the in- 

44 



G90 DESCRIPTION AND TREATMENT OF INSANITY. 

tellect being temporarily overpowered by its force. It is an 
act, therefore, performed without reflection. The passions are, 
in the normal condition of the individual, more or less under 
the control of the intellect and the will, and the power of 
checking their manifestations is capable of being greatly in- 
creased by self- discipline. Some persons hold their passions 
in entire subjugation, others are led away by very slight emo- :; 
tional disturbances. The law recognizes the natural weak- 
ness of man in this respect, and wisely discriminates between 
acts done after due reflection and those committed in the 
midst of passionate excitement. 

The acts performed during heat of passion may in their 
more obvious aspects, and when viewed isolatedly, resemble 
those done during the manifestation of some one of the forms 
of insanity mentioned. But they are so only as regards the 
acts themselves. Thus, a person entering a room at the very 
moment when one man was in the act of shooting another, 
would be unable to tell whether the homicide was done in 
the heat of passion or under the influence of insanity ; he 
would be equally unable to say whether it was committed 
with malice aforethought or in self-defence. The act, there- 
fore, by itself, can teach us nothing. We must look to the 
attending circumstances and to the antecedents of the perpe- 
trator for 'the facts which are to enlighten us as to the state 
of mind of the actor. 

In the first place, a crime committed during heat of pas- 
sion is the direct consequence of a motive, of which the pas- 
sion is the first result and the act of violence the culmination. 
It is the direct logical consequence of the motive. Heat of 
passion, or anger, manifests itself by unmistakable signs with 
which every one is familiar. Morbid impulses have no such 
accompaniments, the subjects of them evincing none of the 
furious excitement of mind and of body characteristic of rage 
in its most intense form ; and, though in the paroxysms of 
epileptic insanity there is present a series of phenomena sim- 
ilar to those attendant upon furious anger, the absence of mo- 
tive and the existence of unconsciousness of the act, as well 
as the previous history of the patient, will suffice to discrimi- 
nate between what he may do and what the person previ- 
ously angry from an obvious cause may do. 

It is, therefore, by a study of the attendant circumstances, 
and by an inquiry into the previous history of the perpetra- 



THE PATHOLOGY AND MOEBID ANATOMY OF INSANITY. 691 

tor of a criminal or violent act, that the distinction between 
snch an act and one committed nnder the influence of any 
form of insanity is to be made. 



CHAPTER XII. 

THE PATHOLOGY AND MORBID ANATOMY OF INSANITY. 

As constituting the basis of many of the forms of insanity, 
and as themselves being one of the classes of mental derange- 
ment described in this work, I thought it expedient, for the 
more thorough elucidation of the subject, to consider the 
pathology and morbid anatomy of illusions and hallucina- 
tions in conjunction with the symptomatology of these affec- 
tions. It will only, therefore, be necessary in the present 
connection to prosecute the inquiry so far as concerns the re- 
maining groups. 

Although these are five in number, they may properly be 
reduced to three — the intellectual, the emotional, and the 
volitional insanities — for the compound and constitutional 
groups, though necessary in a classification for the study of 
symptoms, are in reality composed of combinations in varying 
proportions of the phenomena of the three groups mentioned, 
with certain peculiarities in some instances which can receive 
such special considerations as may be required. 

The part of the encephalic mass with which we have most 
to concern ourselves in the study of the pathology and morbid 
anatomy of insanity is the cerebrum, and the portion of that 
organ to which our inquiries must especially be directed is 
the cortex. From their proximity to and intimate anatomical 
relations with the cortex, the membranes are also of im- 
portance, but this importance is quite secondary to that of 
the structure with which they are in immediate connection. 

We have seen, in the earlier chapters of this work, that 
there is scarcely a doubt that the centres for intellect, emo- 
tion, and will, are seated in the cerebral cortex. It is equally 
certain, therefore, that derangements of either of these cate- 
gories of mental faculties are the results of lesions perceptible 
to our means of research, or imperceptible to all the instru- 
ments of precision we can bring to bear. But whether visible 



692 DESCRIPTION AND TREATMENT OF INSANITY. 

or invisible, tangible or intangible, is really a matter of very 
little consequence, so far as the rationale of insanity is con- 
cerned. For it follows with all possible logical force that, if 
the intellect, the emotions, and the will result, as we believe 
they do, from the action of the gray matter of the cortex in 
its normal condition, the aberrations to which they are sub- 
ject must be due to the action of the gray matter of the cortex 
in its abnormal condition. 

Further than this we cannot at present go. We cannot 
say that this or that particular form of insanity is directly 
associated with lesions of any one portion of the cortex any 
more than we can say that the intellect is derived from this 
part, the emotions from that, and the will from some other. 
Perhaps in time we may acquire this knowledge, but we cer- 
tainly do not possess it now. It is possible, in view of the 
researches of Luys ' and Meynert, 2 that the superior layer of 
cortical cells is concerned with the intellect and the emotions, 
and the lowest with volition, but this cannot yet be considered 
as definitely established. 

Beginning with the intellectual insanities, and locating 
their immediate patho-anatomical cause in the cortex, we 
have to inquire what are the morbid conditions of this part 
of the brain to which they can owe their origin ? Although 
the records of morbid anatomy do not teach us as much as 
we might wish, we are not altogether without information on 
this point. 

In those cases — and they comprise by far the largest pro- 
portion—of intellectual monomania with exaltation and in- 
tellectual monomania with depression, in which there are 
illusions and hallucinations, many instances show, on post- 
mortem examination, the evidences of disease of the optic 
thalamus of one or both sides, in addition to the lesions of 
the cortex associated with the intellectual derangement. 
These latter consist, in recent cases, of dilatation and a tor- 
tuous state of the blood-vessels of a greater or less part of 
the cortex, sometimes of the whole surface of the brain, 
at others of a single lobe, and again of a portion of a lobe or 
of even a single convolution. This condition often extends 
to the membranes, and these may be in patches more or less 
extensive, adherent to each other, to the cranium, and to the 

1 "Recherches sur le systeme nerveux cerebro-spinal," etc., Paris, 1865. 

2 Vierteljahr8chri/t der Psychiatrie, 1867, Heft i, p. 77 et seq. 



THE PATHOLOGY AND MORBID ANATOMY OF INSANITY. 693 

cortex. In addition, there are often the lacuna? of the peri- 
vascular canals, made by the distended blood-vessels, and re- 
maining after the contraction of these latter at death. These 
are found both in the gray and white matter. 

These changes, which were noticed by the older writers, 
Foville, 1 Parchappe, 8 Fischer, 3 Ekker,* and others, have been 
confirmed by later observers, among them Griesinger, 6 Bind- 
fleisch, 6 Tuke, T Luys, 8 and Voisin. 9 Sometimes there is a 
diffused redness extending over portions of the brain, and 
again there is a swelled or turgid condition of one or more of 
the convolutions. 

Microscopically it is found that the vessels of the cortex 
are often obstructed by agglomerations of red corpuscles, that 
the lymphatic sheaths are infiltrated with fatty matter, that 
the smaller vessels are distended and tortuous, that minute 
extravasations have taken place, and that there are deforma- 
tions of various kinds in the nerve-cells. Sometimes these are 
swollen, at others atrophied ; again, they have lost to a 
greater or less extent their processes ; and, again, they are 
infiltrated with fatty and other granular matter. Sometimes 
there is pigmentation of certain portions of the cortex. 

Yoisin 10 reports an instructive case, of which I give the 
following abstract : 

L., a woman forty-one years of age, with some hereditary 
tendency to neurotic disturbances, and of an impressionable 
character, became smitten while in church with a missionary. 
Becoming jealous, she was angry if he spoke to any other 
woman, and finally accused him of sending men to her apart- 
ment to insult her. After the missionary departed to foreign 
regions, her fury against him increased, and she made many 

1 Dictionnaire med.-chir. pratique, art. "Aliens," Paris, 1829, t. i. 

2 " Recherches sur Fencephale," Paris, 1836-'42, p. 90. 

3 " Pathologisch-anatomisch Befunde im Leichen von Geisteskranken," Lu- 
cerne, 1854. 

4 "De cerebri et medullae spinalis vase-rum," Utrecht, 1853. 

6 " Mental Pathology and Therapeutics," New Sydenham Society Translation, 
p. 427. 

6 "A Text-Book of Pathological Histology," American translation, Philadel- 
phia, 1872, p. 644. 

7 British and Foreign Medico- Chirurgical Review, April, 1873. 

8 "Traite clinique et pratique des maladies mentales," Paris, 1881, pp. 336, 
392. 

9 "Lecons cliniques sur les maladies mentales," etc., Paris, 1883, p. 56. 

10 Op. cit., p. 60. 



694 DESCRIPTION AND TREATMENT OF INSANITY. 

attacks on persons in the street whom she mistook for him. 
Then she was arrested and placed in the Salpetriere. It was 
found that her memory was good for names, things, and 
events ; articulation normal ; often spoke to herself ; at times 
exaltations ; hallucinations of sight and hearing ; ideas of 
persecutions. Two years after admission — her mental aber- 
ration continuing — she died of typhoid fever. 

The encephalon weighed 1,130 grammes. There was no 
atheroma of the cerebral vessels visible to the naked eye. No 
thickening or adhesions of the meninges, no sub-arachnoidal 
effusion. Cranial nerves healthy, except the eighth pair, 
which were softened. Bulb and protuberance normal. The 
most internal part of the fissure of Sylvius was covered with 
a thickened, tough, and opalescent arachnoid, as was also the 
region in front of the chiasma. The gray olfactive centre of 
the right sphenoidal lobe presented to the unaided sight 
many black points and aborizations in large numbers. The 
left gyrus hippocampi presented also this dotted appear- 
ance. 

There was a red punctation of the left tubercular quadri- 
gemina. In the space between the corpora geniculata externa 
and interna there were little lacunae and slight depressions. 
A horizontal section of the left hemisphere showed that in 
front the gray substance was of ordinary color and thickness, 
but the first frontal convolution (the ascending frontal of 
Meynert) presented at its most interior part an abnormal 
appearance characterized by the existence of a general yel- 
low tinge and of a well-defined yellow zone of the breadth 
of m., .001, which divided the gray substance of this con- 
volution into two very nearly equal parts. This state was 
found, though to a less extent, in the left second parietal 
convolution (first parietal of Meynert). 

Throughout these altered parts the vessels were found to 
be larger than was normal, as were also those of the subjacent 
white substance. 

The gray centre of the right optic thalamus was in more 
than a normally vascular condition, and on antero-posterior 
section it was seen to be very vascular. In the part imme- 
diately subjacent to the olfactive centre there was a little spot 
the color of lees of wine, and a corresponding depression. 
There was a lacuna in the middle part. 

A portion of the gray substance of one of the parietal con- 



THE PATHOLOGY AND MOKBID ANATOMY OF INSANITY. 695 

volutions was submitted to microscopical examination, with 
the following results : 

1. There was a large number of vessels of which the lym- 
phatic sheaths were infiltrated with oil-globules. 

2. Many vessels were gorged with red corpuscles. 

3. Many cells were infiltrated with orange-yellow fat-gran- 
ules. 

4. There were several extravasations. 

A part of the olfactive centre of the right sphenoidal lobe, 
where the black points existed, showed — 

1. A large vessel completely gorged with red corpuscles. 

2. A mass of orange-yellow hsematine crystals. 

3. A large number of dark-brown extravasations along the 
course of the vessels. 

4. Many fatty cells. 

5. Masses of hsematoidin and hsematin in the lymphatic 
wall of some of the vessels, especially at the points of bifur- 
cation. 

The examination, therefore, showed the existence of con- 
gestion of one optic thalamus and of one sphenoidal lobe, with 
lesions of the parietal convolutions. 

The following case, from my own experience, afforded sim- 
ilar results : 

I. L., a man aged forty- five, came to my clinique at the 
University of New York, in November, 1876, and several times 
thereafter. He had the delusion that he was about to receive 
a large fortune, and was in consequence in a mild state of ex- 
altation. At the same time he had hallucinations of persons 
speaking to him and advising him what to do with his money 
when he received it. These were supposed to come from both 
living and dead persons. Among the former were Queen 
"Victoria, General Grant, Victor Hugo, and the King of Swe- 
den, the latter being the chief adviser. His physical symptoms 
consisted mainly of pain in the head, vertigo, and insomnia. 
There were no oculo-pupillary symptoms, and his articulation 
was normal. He talked a good deal, but without much inco- 
herence. I diagnosticated the case as one of intellectual 
monomania, with exaltation. 

In February, 1877, he died of dysentery, and, assisted by 
Dr. Charles T. Whybrew, my clinical assistant, I made the 
post-mortem examination. The brain only was examined. 

There were no adhesions of the dura mater to the skull, 



096 DESCRIPTION AND TREATMENT OF INSANITY. 

but the meninges were, at a point beginning at the middle 
of the right posterior central convolution and extending 
down to the horizontal branch of the fissure of Sylvius, ag- 
glutinated to each other and adherent to the cortex. Over the 
upper, middle, and lower frontal convolutions of the right 
frontal lobe, there were opalescent patches and subarach- 
noidal effusions. The membranes in all other regions ap- 
peared to be healthy. They were removed as carefully as 
was practicable, though it was impossible to avoid tearing 
the cortex a little at the place of adherence. A vertical sec- 
tion was made through both hemispheres immediately in front 
of the corpus callosum, and including the anterior parts of 
the upper, middle, and lower frontal convolutions. Numerous 
puncta vasculosa were seen, both in the gray and white sub- 
stance, in the right frontal lobe, but no abnormal appearance 
in the left. Another section, carried through both hemi- 
spheres, an inch posterior to the first, and passing through the 
middle of the convolutions mentioned, showed like appear- 
ances in the gray and white substances ; and a third section, 
carried through both hemispheres between the optic chiasm 
and corpora albicantia, and through the part on the right 
hemisphere at which the adhesions existed, showed an in- 
creased state of congestion ; the puncta vasculosa were much 
more numerous, the cribriform state was well marked, and the 
gray matter of the convolutions was of a decided pink tinge. 

The optic thalami were of normal appearance, as were also 
all other parts of the brain except those specified. Sections 
through the posterior regions of the parietal lobes and through 
the occipital lobes showed no evidences of congestion in any 
part. 

Portions of the gray matter of the frontal and central con- 
volutions were taken for microscopical examination. 

Inspection of sections of the fresh tissue, made while it 
was frozen, and then colored with aniline red, showed decided 
enlargement and increased tortuosity of all the blood-vessels. 
Most of them were choked with masses of red corpuscles, and 
in several places the walls of the vessels had given way, and 
extravasations had taken place. These changes were espe- 
cially noticeable in sections taken from the anterior central 
convolution, which appeared to be the centre from which the 
morbid process radiated. At the bifurcations of many of the 
vessels deposits of finely granulated, highly refractory matter 



THE PATHOLOGY AND MORBID ANATOMY OF INSANITY. 697 

were found, and along the course of the smaller vessels collec- 
tions of crystals of hsematoidin were scattered, and at the bi- 
furcations they were collected in masses. In a section taken 
from the superior frontal convolution there were several ves- 
sels, the calibre of which was entirely filled with masses of 
red corpuscles. 

In all the specimens there were hypertrophied or inflated 
cells — not in the internal layers, as described by Drs. Batty 
Tuke, and Rutherford, but in the external layer. These were 
most numerous in the sections from the central convolutions. 
The nuclei of these cells were surrounded with granular mat- 
ter, and had lost in sharpness of outline. 

There was decided proliferation of the nuclei of the neu- 
roglia, but no other abnormal feature was observed. 

All these conditions were confirmed by the examination of 
prepared sections, and large numbers of minute extravasa- 
tions were discovered which were not seen in the fresh speci- 
mens. 

In chronic intellectual mania like changes are detected, 
and as the affection advances they all become more pronounced. 
Degeneration of the cells of the gray matter takes place. 
They lose their processes, and fatty granulations and pigmen- 
tary deposits occur in large numbers. Patches of discolora- 
tion are found on the surface of the convolutions, and upon 
microscopical examination these are seen to consist of frag- 
ments of the vessels, masses of pigment, and extravasations. 
Degenerations of the vessels, atheromatous and calcareous, 
are also often perceived. Miliary aneurisms are not uncom- 
mon, and it is from the rupture of some of these that the 
extravasations are generally produced — though they are 
sometimes formed by the giving way of the vessels in con- 
sequence of the obstruction caused by impacted red cor- 
puscles. 

Reasoning mania being the result of congenital condi- 
tions, which, although deviating from the normal standard, are 
not due to existing disease, it is to the structure of the brain 
and of the cranium that we have to look for the evidences of 
the mental aberration. Hence, we should not expect to find 
congestion or abnormalities in the individual cells, but rather 
variations in the size and direction of the convolutions in the 
shape of the lobes, and in the development of parts of the 
brain, or of the organ as a whole. 



09S DESCRIPTION AND TREATMENT OF INSANITY. 

There are no lesions in reasoning mania, so far as we know. 
As Campagne ! says, the morbid anatomy has yet to be discov- 
ered. Moreover, as the affection is not one which of itself 
tends to death, the opportunities for making post-mortem ex- 
aminations have been few, and these few have not been im- 
proved, mainly for the reason that until quite recently the 
attention of alienists has not been directed to the subject. 
Nevertheless, we have some data derived from the study of 
the crania of living reasoning maniacs, and the results of one 
post-mortem examination, that of Guiteau. 

Campagne found from the measurements of the heads of 
the reasoning maniacs, compared with those of sane persons, 
lunatics, and idiots, as determined by Panchappe, that the 
following differences were observed : 

1. That the head is smaller than that of persons of sound 
mind. 

2. That it is smaller than that of lunatics in general. 

3. That as regards size it is about equal to that of persons 
of weak minds. 

4. That it is larger than that of idiots. 

5. That the antero-posterior curve, and particularly the 
posterior curve of the cranium, are less than those of persons 
of sound mind, lunatics in general, the weak-minded, and even 
of idiots. It may be said that reasoning maniacs have a con- 
genital atrophy of the posterior lobes of the brain, and that 
the cranium has been diminished in size to the detriment of 
the occipital region. 

In the case of Guiteau, disregarding the lesions which in- 
dicated that he was passing into the initial stage of general 
paralysis, we find that he had an unsymmetrical cranium, the 
right side being smaller than the left, and that there was a 
marked flattening of the occipital region. The examination of 
the brain made by Drs. W. J. Morton and C. L. Dana, a three 
quarters of an hour after execution, with all the thorough- 
ness and care of which the circumstances permitted, showed 
that the organ deviated in many respects from the typical 
standard. 

Thus, it is stated that "the frontal lobes were peculiarly 
shaped. Looking at them from in front and above, they pre- 

1 " Traits de la manie raisonnante," Paris, 1869, p. 208. 

2 The Journal of Nervous and Mental Diseases, New York, July, 1882, p. 
613. 



THE PATHOLOGY AND MORBID ANATOMY OF INSANITY. 

sented two protruding points from which the surface sloped 
away in a concave curve. This pointed apex of the lobes, 
with the concavity of the orbital and beginning of the frontal 
surface, was carefully noted by all of us at the first exposure 
and removal of the brain." 

Then, among more or less abnormal features, it is stated 
that the upper part of the post-central convolution was nar- 
row and shrunken ; that the right prsecentral lobule was 
quite small ; that the fusiform lobule was smaller on the left 
than on the right side; and that, to sum up, "the brain 
was marked by an unusual number of cross and secondary 
fissures, especially in the frontal lobes, that it was not of the 
confluent-fissure type, and that the convolutions on the two 
sides were quite asymmetrical." 

It is to be regretted that microscopical examination of the 
fresh brain was not made, and that facilities were not at hand 
for accurately weighing the organ, for determining its spe- 
cific gravity, and for measuring its chords and arcs, its con- 
tour and shape. As it is, however, the data obtained are 
sufficient to show that the brain of this man was of abnormal 
construction. 

In regard to intellectual subjective and objective morbid 
impulses, there are no data on which to found their morbid 
anatomy, except such as are derived from a consideration of 
the symptoms observed during life. Here, the vertigo, pain 
in the head, and insomnia, and morbid dreams which so gen- 
erally accompany them, and the fact that they frequently re- 
sult from disturbances of the normal action of the brain in 
the way of its excessive use or emotional excitement, point to 
localized hyperemia as their patho-anatomical basis. If the 
views of Luys and Meynert be correct, it is mainly in the 
upper layer of cells of the gray matter of the cortex that we 
should expect to find the evidences of disease. They have 
not yet been found, chiefly, in all probability, because they 
have not been looked for. 

In regard to the emotional insanities, the remarks just 
made are applicable to emotional monomania and emotional 
morbid impulses, the seat of the lesion of which and its exact 
character being not definitely known. But here again the prob- 
ability, from the character of the symptoms, that the latter is 
hyperemia, is very great. Doubtless, however, the seat of the 
lesion is different from that of the intellectual forms specified. 



700 DESCRIPTION AND TREATMENT OF INSANITY. 

Luys embraces intellectual manias, impulsive manias, and 
emotional manias in his class of localized hyperaemias of dif- 
ferent regions of the brain, according to the phenomena mani- 
fested. If the intellect is the result of the action of one part 
of the brain, it may be taken as an analogous fact that the 
emotions come from some other part. Like reasoning is ap- 
plicable to the derangements. 1 

Simple melancholia is regarded by Meynert and others as 
being the result of exhausted brain-action, conjoined with a 
deficient supply of arterial blood. Its patho-anatomical basis 
is from this point of view anaemia, and this state is in un- 
complicated cases that which might reasonably be supposed 
to exist from a study of the phenomena, mental and somatic, 
which characterize the disease. But in melancholia with de- 
lirium, while there may be an anaemic condition of some 
parts of the brain, there is quite certainly a congested state 
of others. The researches of Yoisin a abundantly establish 
this point, and he has been able, in certain cases with impul- 
sions to suicide, to locate the morbid centre with sufficient 
exactness. 

Thus, in the case of a woman, Gris— , who was affected with 
melancholia, with incessant impulsions to suicide, and who, to 
accomplish her purpose, not only starved herself but stuffed 
her mouth with linen, he found that she carried her hand to 
the cortex, and that there was an elevation of the temperature 
of that part to the extent of two degrees above that of the 
axilla. She died of inanition four days after admission to the 
Salpetriere, and on post-mortem examination the meningeal 
veins which run to the right and left over the internal part of 
the ascending frontal convolutions, the first and second pari- 
etal, and the most anterior and internal part of the occipital, 
were found gorged with blood, and the meninges themselves 
were thickened and in a hypersemic condition. In addition, 
there was a serous cyst, the volume of a small apple, which 
rested on the left parietal convolutions. Besides all this, an 
antero-posterior and horizontal section of each hemisphere, 

1 See the author's " Cerebral Hyperemia the Result of Mental Strain or Emo- 
tional Disturbance," New York, 1879, read before the New York Neurological 
Society, November 7, 1877 ; also, " On the Effects of Excessive Intellectual Ex- 
ertion," Bellevue and Charity Hospital Reports, New York, 1870 ; also, " A Trea- 
tise on Diseases of the Nervous System," New York, 1871, and seventh edition, 
1881. 

2 " Lecons cliniques sur les maladies mentales," Paris, 1883, p. 176. 



THE PATHOLOGY AND MORBID ANATOMY OF INSANITY. 701 

made at the depth of a centimetre, showed the existence of a 
reddish scarlet tinge in the most internal part of the left 
ascending frontal and first parietal convolutions, and of the 
first right parietal. 

In another instance, a woman, Chaub., was melancholic, with 
such persistent impulsions to suicide that it was not safe to 
leave her alone for an instant. She had tried to hang herself, 
had then cut her throat, opening the larynx, and had then 
refused to eat, so that it was necessary to feed her through a 
tube. She complained of fronto-vertical pains, and the tem- 
perature was above the normal standard. She died, and the 
autopsy showed the existence of a marked degree of menin- 
geal congestion in the fissure between the first frontal and as- 
cending frontal convolutions on the surface of the first pari- 
etal, and of the contiguous regions. 

These data are important, for they are applicable not only 
to conditions in which there are impulsions to suicide, but to 
morbid impulses of all kinds. 

In melancholia with stupor there is, in the first p]ace, a 
generalized passive congestion of the brain and its mem- 
branes, and this is followed, as Etoc-Demazy pointed out 
nearly fifty years ago, by an infiltration of serum into the 
hemispheres, by which the convolutions are subjected to pres- 
sure from within, and are, consequently, flattened against the 
cranium. 

Occasionally there is also, as I have seen in several cases, 
subarachnoidal effusion. 

Luys ' is of the opinion that the condition is often the re- 
sult of vaso-motor spasm, by which the nervous elements are 
deprived of their proper supply of blood. 

In those cases in which there is at the same time a certain 
amount of sensorial aberration there is, according to Luys, 
a hypersemic state of the optic thalami. Thus, a condition of 
stupor due to the arrest of intellectual emotional activity 
and volition can coexist with hallucinations of one or more 
of the special senses. 

In hypochondriacal mania or melancholia the condition 
in the first instance is a passive congestion of some parts with 
active congestion of others. As this is an affection character- 
ized by the presence of vivid illusions and hallucinations, the 
optic thalami are in a state of active hypersemia. As Luys a 

1 Op. cit, p. 508 et seq. s Op. cit., p. 509. 



702 DESCRIPTION AND TREATMENT OF INSANITY. 

says: "We see in certain cases of hypochondria and mel- 
ancholia that, while different parts of the cortex are in a state 
of complete repression, the central regions (the opto-striated 
bodies) are in a condition of very intense vascularization. 
This is a very significant fact, and one that demonstrates to 
us how in the same brain certain regions can be in a state of 
ischsemia and certain others be very strongly congested. Thus, 
there are two series of phenomena of quite different natures — 
one marked by excitation and the other by depression." 

But, as the results of the long- continued action of these 
conditions, permanent alterations of the vessels (even to the 
extent of their obliteration), sanguineous cysts, adhesions of 
the meninges, softening, and morbid growths of various kinds, 
are apt to be produced in different parts of the brain. 

Relative to the pathological anatomy of hysterical mania, 
no very definite results are at hand. The probability, how- 
ever, is that the disease is the result of vaso-motor disturb- 
ances in the cerebral circulation, of the nature of both spasm 
and paralysis of the vessels. 

In epidemic insanity, there have been no post-mortem ex- 
aminations of the brain made according to the principles of 
modern research. It is also probably the result of vaso-motor 
disturbance. 

The volitional insanities are likewise due to changes in 
the blood-supply of certain parts of the brain, probably in 
the lower layers of cortical cells. Although we have no data 
based upon post-mortem examination to support this view, 
analogy, however, would lead us to the belief that a volitional 
morbid impulse can be the result of a limited hyperemia of 
one portion of the brain, just as intellectual or emotional mor- 
bid impulses can result from a like condition existing in 
other parts. In those cases in which the individual suddenly 
experiences an impulse to the perpetration of an act not dic- 
tated by an idea or an emotion, the excitation is volitional, 
and it doubtless results from hyperemia of the volitional 
centre from vaso-motor paralysis. 

In aboulomania or paralysis of the will, the usual patho- 
anatomical condition is probably that of vaso-motor spasm, 
by which the volitional centre is deprived of its due supply 
of blood, and hence reduced to an anaemic state ; but, as the 
disease is not one which ever terminates fatally, there are no 
positive data to support this opinion. In some cases the 



THE PATHOLOGY AND MORBID ANATOMY OF INSANITY. 703 

symptoms appear to indicate the existence of cerebral hy- 
peremia. 

As would reasonably be expected, the class of compound 
insanities exhibits great diversities in the character of the 
patho-anatomical results. In acute mania there is a general 
hypersemic condition of the brain and its membranes, and the 
various secondary states which result therefrom. Not only 
is there intracranial congestion, but the scalp and the bony 
tissue of the cranium are similarly affected. 

On attempting to raise the cranium after it has been en- 
tirely sawn through, it is often found that the dura mater has, 
throughout a greater or less part of its extent, become adher- 
ent to the inner surface of the cranium, and that considerable 
force is required to detach it from its connections. This 
membrane is seen to be injected, and the sinuses are usually 
gorged with blood. Sometimes it is adherent to the arach- 
noid at different places, again it is separated from this mem- 
brane by effusions of serum, and again both conditions exist. 
This exudation may be clear, or red from admixture with 
blood or its coloring matter. At times the exudation con- 
sists entirely of extra vasated blood from the rupture of one 
or more of the over-distended vessels. The arachnoid and 
pia mater participate in the congested condition. The vessels 
are seen to be enlarged and tortuous, and there are discolored 
patches, some red and others opalescent, throughout their ex- 
tent. Exudations in the meshes of the pia mater* of serum, 
clear or bloody, are common occurrences, and the membranes 
themselves are thickened. The Pacchionian bodies are al- 
most always enlarged and congested. 

On removing the meninges, the cortex is found bathed in 
serum, or the membranes are adherent to it either in patches 
or throughout the greater part of its extent. Sometimes 
there are reddish patches on the surface of the convolutions, 
and, on section, the evidences of congestion are found in the 
presence of minute extravasations of blood or puncta? vascu- 
loso3, or of a generally diffused reddish tinge. Occasionally 
certain of the convolutions appear to be swollen or distended. 

Section through the white substance shows that the mor- 
bid process has extended to this tissue, there are numerous 
punct& vasculosa, the cribriform state is well marked, and 
there are vascular arborizations in different regions. 

The basal ganglia and the cerebellum are also involved in 



704 DESCRIPTION AND TREATMENT OF INSANITY. 

the congestive condition, and the ventricles contain more than 
the usnal amount of fluid. 

. Sometimes the whole encephalon is softened, or this con- 
dition may exist only in the cortex or in other limited por- 
tions of the brain, though this may sometimes be a, post-mor- 
tem change. 

In the case of a gentleman suffering with acute mania, 
characterized by hallucinations of sight, hearing, and taste, 
delusions, high delirium, incoherence, and paroxysms of 
maniacal fury, during which he attempted to injure those 
around him, I aspirated the liver for abscess, and evacuated 
about eight ounces of pus. The maniacal condition, however, 
continued, and on the ninth day subsequently he became 
comatose, and on the tenth day death ensued. 

The post-mortem examination was made by my son, Dr. 
Gr. M. Hammond, 1 in my presence, and that of Dr. P. B. 
Wyckoff, of this city. The dura mater was found to be firm- 
ly attached to the cranium throughout the frontal and pari- 
etal regions of both sides, and increased in thickness. Under 
the dura mater, spots of a grayish-white exudation were 
found scattered over the entire convex surface of the cere- 
brum. Between the arachnoid and the pia mater a consider- 
able quantity of bluish effusion was observed, and the pia 
mater was adherent to the brain substance. On microscopical 
examination of prepared specimens, no deviation from the 
normal aspect was observed in the size, development, or num- 
ber of the small or large cells of the gray substance of the 
cortex. Both the gray and white substance were permeated 
by great numbers of blood-vessels, all in a state of intense 
congestion. The duration of the attack was a little over a 
month. 

In periodical insanity there are no specially characteristic 
features of a patho-anatomical character different from those 
of the form which is repeated. The complete disappearance 
of the accession is the strongest possible evidence in favor of 
the view which ascribes the seizure to disturbances in the 
blood-supply to the brain. 

Hebephrenia, depending as it does upon arrest of de- 
velopment, and psychical degeneration supplemented by dis- 
turbances of the circulation of blood in the brain, should pre- 

1 " A Case of Acute Mania with Abscess of the Liver," by Graeme M. Ham- 
mond, M. D., Journal of Nervous and Mental Disease, April, 1882, p. 300. 



THE PATHOLOGY AND MOKBID ANATOMY OF INSANITY. 705 

sent, on post-mortem examination, the characteristics of these 
conditions. I am not aware, however, that any patho-anatomi- 
cal examinations of persons dying of the affection have been 
made. 

Circular Insanity. — In the most recent work on the sub- 
ject of this form of mental derangement, that of Bitti, 1 noth- 
ing is said relative to its patho-anatomy. In patients, how- 
ever, dying during either the period of excitement or that of 
depression, we should expect to find the evidences of conges- 
tion, though probably in different parts of the brain. Or it 
may be that, in death occurring during the period of excite- 
ment, a state of hyperemia would be found to exist, while 
in that taking place during the melancholic stage a spasm of 
the vessels causing anaemia would be discovered. 

Katatonia. — Post-mortem examinations of the nerve-cen- 
tres in this disease have been made by Kahlbaum 2 and by 
Kiernan, 3 assisted by Spitzka. In one case, the details of 
which are given by Kiernan, the dura mater was adherent to 
the cranium in patches ; there were firm coagula in the veins 
and sinuses ; the arachnoid, especially over the fissure of 
Sylvius, was very opaque ; the pontico-chiasmal lamina were 
very dense, and a false membrane was formed beneath. Epi- 
thelial granulations were present in a rudimentary condition ; 
the pia mater was nowhere adherent to the cortex except over 
the frontal lobe. The cortex was pale, and there was a de- 
cided sinking of the surface of certain gyri below the neigh- 
boring convolutions. There was a fusion of the opposite 
sides of the anterior cornua of the lateral ventricles. Cysts 
of the choroid plexus were also present. 

In another case, the subarachnoid space was filled with a 
number of brownish flakes of a gelatinous consistency. Most 
of these drained away with the cerebro-spinal fluid, but a few 
were quite firmly adherent to the underlying pia mater. Mi- 
nute blackish or dark-brown grains were disseminated through 
them, probably exudative products (?), cerebello-medullary 
lamina opaque, with whitish dense bands. Sylvian fissure 
slightly opaque. Along the vessels of the pia mater, minute 
pale-yellowish, whitish, and reddish bodies were found, which 
were supposed to be tuberculous. In the Sylvian fissure over 

1 " Traite clinique de la folie a" double forme," Paris, 1883. 
3 " Die Katatonia," op. cit. 

3 " Katatonia," The Alienist and Neurologist, October, 1882, p. 558 et seq. 
45 



706 DESCRIPTION AND TREATMENT OF INSANITY. 

the island of Reil there was a fusion of the lepto-meninges. 
The condition of the blood-vessels is minutely described. It 
may be said of the veins, in general terms, that they presented 
all the evidences of congestion, being filled with coagula or 
with thrombi. The white substance generally showed nu- 
merous punctce vasculosce, all of a strikingly venous character. 
The arteries were in general empty, both in the white matter 
and in the cortex. The lining membrane of the ventricles 
was the seat of venous injection, and a mucoid substance cov- 
ered the floor of these cavities. 

The microscopical examination was made by Dr. Spitzka, 
and is the only one of the kind, so far as I know, on record. 
It is expedient, therefore, to cite it in full : 

"The mucoid matter on the floor of the fourth ventricle 
was found to consist of an accumulation of round cells, not 
surpassing a red blood-corpuscle in diameter, some nucleated, 
others not ; all were perfectly colorless. Interspersed among 
them were larger elements, identical in every respect with 
white blood- corpuscles. Isolated bodies of an oblong shape, 
with a distinct nucleus and pellucid protoplasm, were noticed. 
All these were embedded in a granular mass, which showed a 
formation of imperfect fibrils. The arachnoid exudation 
consisted of the same matters, together with a fair proportion 
of red corpuscles, large flakes of pigment, and round spheres 
of a protein nature. The pia mater of the convexity exhibited 
numerous small nodules, most of which were molecular, others 
calcareous, and a few contained large and small poly -nucle- 
ated cells. These nodules were periadventitial, and hardly 
visible to the naked eye. The cortical substance of the island 
of Reil showed a marked increase of the nuclei of the neu- 
roglia. The ganglionic cells, both pyramidal and fusiform, 
were normally contoured ; processes well developed ; proto- 
plasm healthy, in some cases diffusely pigmented ; and nu- 
cleus round and clear. Free lymphoid bodies were accumu- 
lated in the peri-cellular spaces in prodigious numbers ; in 
one instance, no fewer than twenty-three of these cells could 
be distinguished clustering round one pyramidal nerve-cell 
of the third layer. Frequently the nerve- cell was altogether 
hidden from view by such cell-groups. In this respect, the 
island of Reil presented marked original differences. It was 
found that areas varying from a line to an inch in diameter 
were the seat of this appearance, while a similar larger or 



THE PATHOLOGY AND MORBID ANATOMY OF INSANITY. 707 

smaller adjoining area was either less involved or perfectly 
normal in this respect. The transition from the affected to 
the healthy areas was sudden. 

" The coats of all the vessels were entirely healthy, pre- 
senting no deviations from the appearance of cerebral vessels 
in some subjects. The arteries were empty ; the veins and 
many capillary districts rilled with blood-corpuscles ; these 
latter were individually distinct, not compressed or fused by 
crowding, as has been described to be the case in the stasis 
accompanying general paresis. This engorgement was most 
marked in those areas in which the accumulation of lymphoid 
bodies was farthest advanced. The periadventitial space was 
filled with similar bodies in the case of the vessels referred to. 
The same appearances in a less degree were noticed in the 
operculum and the convolutions bordering the anterior part 
of the great longitudinal fissure. The remainder of the cor- 
tex cerebri appeared perfectly healthy. The accumulation of 
lymphoid bodies was still more marked in the nucleus len- 
ticularis than in the clau strum and island of Reil. The cere- 
bellum, olivary bodies, nuclei of the cranial nerves, corpus 
striatum, thalamus, and corpora quadrigemina presented no 
deviations from the normal standard." 

There was also incipient sclerosis of the antero-lateral and 
posterior columns of the spinal cord. From these data, Dr. 
Kiernan expresses the opinion that the characteristic patho- 
logical condition of katatonia is an inertia of the vaso-motor 
centres, whose consecutive injurious effects were concentrated 
on the parts lying at the depth of and around the fissure of 
Sylvius. Every other lesion is to be considered as secondary 
or accidental. 

Bearing in mind the readiness with which the cases that 
have come under my observation underwent amelioration and 
cure, I have no hesitation in entirely concurring in this 
opinion. 

Primary dementia is doubtless, in the very beginning, the 
result of vaso-motor spasms and consequent cerebral anaemia. 
The often sudden manner of its appearance as the result of 
severe emotional disturbances, and the character of the symp- 
toms point indubitably to this factor as the pathological 
cause. But in the late stages of the disease the patho-anat- 
omy does not probably differ essentially from that of secon- 
dary and senile dementia, and hence they can well in this 



70S DESCRIPTION AND TREATMENT OF INSANITY. 

relation be considered together. Dementia may be regarded 
as the hopper to which nearly all forms of uncured mental 
derangement finally come. Hence, there is often a multi- 
plicity of lesions, adherences, extravasations, neoplasms of 
various kinds, serous exudations, either diffused or encysted 
softening, induration, etc. 

But, notwithstanding the difficulty of determining from 
this embarras de richesses the essential characteristics of de- 
mentia, some steps in advance have been taken, so that we 
are not altogether without definite information on the subject. 

Foville * was one of the first, if not the very first, to notice 
that one of the most constant patho-anatomical features of 
dementia was a diminution of the size of the convolutions, 
and at the same time a paleness and hardness of their sub- 
stance. Frequently they were flattened, as if pinched between 
the fingers. The fissures on the surface of the brain became 
wider and deeper as the convolutions became smaller, and, as 
the nervous substance disappeared, serum contained in the 
commissures of the pia mater took its place. 

Marce a found that in senile dementia there were atrophy 
of the convolutions, alterations of the nerve-cells and fibers, 
and alterations of the capillaries. The alterations of the 
nerve-cells and fibres consisted of atheromatous and fatty de- 
generations ; the former were seen to have lost their processes 
and to be covered with yellow, fatty granules, while many had 
entirely disappeared. Sometimes these altered cells were few, 
at other times there was scarcely a single one that had not 
undergone change. 

The nerve-fibres were deformed and covered with fatty 
granulations. Later, the contents had disappeared, and they 
consisted of nothing but a knotted cylinder of an amber- 
yellow color. At a further stage there was nothing but the 
sheath, and, still later, the whole fibre had disappeared. 

The internal wall of the capillaries was lined with yellow, 
fatty granulations, which often completely filled the calibre. 
Sometimes an aggregation of crystals of hsematin helped to 
close the vessel. 

Dementia, therefore, is characterized by atrophy, which 
affects both the gray and white matter. With this atrophy 

1 " Dictionnaire de medecine et chirurgie pratiques," t. i, Paris, 1829, art. 
" Alienation mentale." 

2 " Recherches sur la d6mence senile," Gazette medicale de Paris, 1863. 



THE PATHOLOGY AND MORBID ANATOMY OF INSANITY. 709 

there is sclerosis. In fact, the condition is due to diffuse 
inflammation of a low form, causing the proliferation of the 
connective-tissue elements and the deformation and disappear- 
ance of the nerve-tissues. To the condition, the term diffused 
cerebral sclerosis may properly be applied. Cotard * has de- 
scribed this condition in other relations, and I a have consid- 
ered it mainly as it occurs in infancy and in connection with 
other symptoms than those of a mental character. 

Among the most thorough observations relative to brain 
atrophy as the essential patho-anatomical condition associated 
with dementia are those of Dr. Bucknill. 3 

The general result arrived at was, that : 

"In cases of chronic mania, of dementia following mania, 
and of primary dementia, the amount of cerebral atrophy may 
generally be calculated upon by the enfeeblement of mental 
power. In all these forms of disease we have found some 
amount of atrophy, and have for the most part found this 
amount to correspond with the amount of mental decadence 
estimated with its duration. . . . 

"It must not be thought that extensive atrophy is only 
found where the mental symptoms are solely those of impair- 
ment or loss of function. It is not inconsistent with much 
mental excitement or with numerous delusions ; but such ex- 
citement is powerless, and the delusions are transitory and 
puerile." 

Upon the whole, therefore, it may be considered that the 
essential patho-anatomical feature of dementia in all its 
forms — primary, after it has passed the earlier stage, secon- 
dary, and senile — is general and interstitial atrophy of the 
brain substance. Not only is the brain, especially the cere- 
brum, diminished in size, but the convolutions are changed in 
form as well as in volume ; and it is directly to these changes — 
just as in progressive muscular atrophy there is a loss of mus- 
cular power — that the enfeeblement of the intelligence is due. 
The flashes of excitement and the childish delusions that some- 
times occur are no more in comparison with normal brain- 

1 "Etude sur l'atrophie partielle da cerveau," Paris, 1868. 

! "A Treatise on Diseases of the Nervous System," seventh edition, New- 
York, 1881, chapter xii, "Diffused Cerebral Sclerosis." 

3 "The Pathology of Insanity," British and Foreign Medico- CMrurgical Re- 
view, January, 1855 ; also, " A Manual of Psychological Medicine," fourth edi- 
tion, London, 1879, p. 52G. 



710 DESCRIPTION AND TREATMENT OF INSANITY. 

action than are the fibrillary contractions of the mnscnlar 
fibres in progressive muscular atrophy in comparison with 
strong voluntary muscular efforts. 

General Paralysis. — The morbid anatomy of this disease 
has been more thoroughly studied than that of any other form 
of insanity, and the results are on a basis of greater certainty 
than can be affirmed of any other variety. From the very in- 
ception of the discovery of its existence, results of more or 
less definiteness have been obtained, until now the essential 
nature of the affection is scarcely a matter of any doubt. 

Beginning with the naked-eye appearances, and then pass- 
ing to the consideration of the results of microscopical exami- 
nation, I shall endeavor to present to the reader a concise view 
of what may be considered as established facts relative to the 
patho-anatomy of the disease in question. In order to do this, 
I shall omit the consideration of many associated conditions 
which, however interesting in themselves, are not characteris- 
tic of general paralysis, and are mostly to be regarded as acci- 
dental complications. 

The scalp and cranium are often found congested. In the 
latter, the diploe is injected and of darker color than is nor- 
mal. 

On removing the calvarium the dura mater is seen to be 
of a dark color, its vessels to be distended ; sometimes there 
is an effusion of serum between it and the cranium, but more 
generally it is adherent in different places, but especially in 
the frontal and vertical regions. False membranes and ex- 
travasations of blood, constituting the condition known as 
pachymeningitis, are present in about one fourth of the cases. 
Besides these, there are occasionally other cystic growths be- 
tween the dura mater and the arachnoid, and adherent to the 
first-named membrane. Generally they contain blood, at 
other times serum. 

The arachnoid is thickened, discolored, congested, and 
covered with opalescent or reddish patches, especially on the 
frontal and parietal lobes. Sometimes there is an effusion of 
serum in large quantity separating this membrane from the 
pia mater. Again, they are adherent one to the other. 

The pia mater is almost invariably thickened, congested, 
and its vessels, the veins especially, enlarged and tortuous. 
The consistence of the membrane is altered so that it is tough 
and resisting and inelastic. Throughout its extent, but nota- 



THE PATHOLOGY AND MORBID ANATOMY OF INSANITY. 711 

bly over the frontal and parietal lobes, there are extravasa- 
tions of blood of small size, and consisting for the most part 
of red corpuscles and hsematine. 

Granulations first described by Boyle are met with mostly 
in the membrane lining the ventricles, but also on the upper 
surface over the convex portion of the cerebrum. They are 
due to a proliferation of the connective tissue of the mem- 
brane. 

Adhesions of the pia mater to the cerebral convolutions 
are the most common of all the naked-eye patho- anatomical 
features of general paralysis. I have never seen a case of 
post-mortem examination of the brain of a general paralytic in 
which they were absent. They are most common over the 
frontal and parietal lobes, but are met with not only at the 
convex surface of the cerebrum, but also over the basilar sur- 
face. These adhesions exist only between the pia mater and 
the summits of the convolutions, and, when the membrane is 
stripped off, a portion of the gray tissue comes with it, leaving 
the surface of the brain at the points of adhesion torn, rough, 
and of a reddish appearance. Sometimes the adhesion affects 
the cortical substances only to the thickness of a sheet of 
letter-paper, and again nearly the entire depth of the gray 
matter is involved. It is never the case that the adhesions 
affect the gray matter of the sulci below the convolutions. 
The summits only are adherent to the membrane. 

Dr. Crichton Browne, 1 on the basis that the six cortical 
layers of nerve- cells are not developed simultaneously but 
consecutively, and that the superior layer, perhaps, being de- 
veloped first, breaks down first, or that, being the seats of a 
greater and more constant degree of activity, they may be 
more liable to suffer from irritation and hyperemia, concludes : 

" 1st, that the adhesions of the pia mater to the gray mat- 
ter of the brain are the most frequent and characteristic of the 
pathological appearances found in general paralysis of the in- 
sane ; 2d, that they are caused by a chronic adhesive inflam- 
matory process springing out of excessive functional irritation, 
and proceeding to disintegration of the cerebral gray matter ; 
and 3d, that, speaking generally, they represent the cause and 
distribution of the morbid processes in which the disease es- 
sentially consists." 

1 "Notes on the Pathology of General Paralysis of the Insane," West Biding 
Lunatic Asylum Medical Reports, vol. vi, 1876, p. 170 et seq. 



712 DESCRIPTION AND TREATMENT OF INSANITY. 

While agreeing with Dr. Browne relative to the hyper- 
activity of the superior layer of nerve-cells of the cortex, I 
think this is to be ascribed to the fact that this layer is, 
as Meynert and Luys have given us reason to suppose, the 
seat of ideation ; that during general paralysis, especially in 
its earlier stages, it is particularly the seat of hyperemia, as 
shown by the derangement of the ideas of the patient, and 
that it is to this localized hyperemia of the superior layer 
of cells that the adhesions with the pia mater are to be as- 
cribed. 

Besides being the seat of adhesions, the cortex is often 
the subject of a diminution of its consistency, and of oedema 
from infiltration of serum. Sometimes it is so soft as to be 
readily washed away by a small stream of water falling on it. 

Atrophy of the convolutions is another patho-anatomical 
feature occasionally met with in general paralysis, especially 
in those subjects of the disease who have survived its presence 
many years. In cases in which death occurs after what may 
be called acute attacks, the white substance presents the cribri- 
form state, and is the seat of numerous punctce vasculosce. 

Section of the gray substance of the cortex shows that it 
is often the seat of discolored spots, or of a general change of 
hue from that which is natural to a yellowish gray or brown 
appearance. 

To sum up the data in regard to the naked-eye appear- 
ances in cases of general paralysis, there are : 

1. A congested condition of the scalp and cranium. 

2. A similar state of the dura mater and arachnoid. 

3. Increased vascularity of the pia mater, with opalescent 
patches. 

4. Adhesions between the pia mater and the summits of 
certain of the convolutions. 

5. Softening of the cerebral tissue. 

6. Change of coloration in the cortex. 

Microscopical Appearances. — Beginning with the blood- 
vessels, we find that the most constant lesion is an endarter- 
itis of the capillaries and arteries, which usually originates 
in the lymphatic sheath, and then extends to the proper coats 
of the vessel. Dr. Sankey ' describes a twisted, or tortuous, 
condition of the arteries of the cortex, and the presence of a 
hyaline substance around the capillaries. Both these states 

1 "Lectures on Mental Diseases," London, 1866, p. 174. 



THE PATHOLOGY AND MORBID ANATOMY OF INSANITY. 713 

are normal, and the latter is the peri- vascular sheath described 
by Robin and His. 

Numerous nucleated bodies are found arranged in groups 
around the vessels, especially at their bifurcations. In addi- 
tion, there are large quantities of red blood- corpuscles and 
crystals of hsematin scattered through the gray tissue, and 
occasionally there is a development of new capillary blood- 
vessels. 

Sometimes the lumen of the vessels is entirely closed by 
masses of red globules, and, again, their coats are the seat of 
dilatations of an aneurismal character. These give way, and 
minute extravasations of blood are the result. 

Mickle 1 found, in regard to the blood-vessels of the cor- 
tex, that many contained aggregations of blood-corpuscles, by 
which they sometimes were completely filled, or were bulged ; 
that there was an increase of the nuclei of the walls of the 
minute blood-vessels ; that sometimes molecular, or pigmen- 
tary, deposits were seen in or upon their walls ; that there 
were occasionally appearances of more or less irregular thick- 
ening or dilatation of the vascular wall ; that now and then 
some vessels had a soft molecular appearance, and fusiform 
dilatation was seen ; and that, more rarely, there were capil- 
lary rupture and extravasation, so that the vessels were sur- 
rounded by minute ecchymoses. 

On the other hand, Spitzka 3 declares that miliary aneu- 
risms, purif orm and dissecting, must be shown to have a defi- 
nite relation to the symptoms of the disease before they can 
be considered of any importance, that often they have been 
produced by faulty methods, and that he has not found a 
single clear appearance of the kind that would stand all 
tests. 

Cerebral Substance. — The examination of the nerve- tissue 
relates to the cells, the fibres, and the connective tissue, or 
neuroglia. 

In regard to the cells of the cortex, many undergo fatty 
degeneration, the nucleus becomes less distinct, and the tissue 
of the cell is altered by the wasting or entire disappearance 
of the processes. Finally, the nucleus is no longer seen, it 
is not even rendered visible by carmine, and the cell appears 

1 " General Paralysis of the Insane," London, 1880, p. 129. 

2 "The Psychological Pathology of Progressive Paresis," Journal of Nervous 
and Mental Disease, April, 1877, p. 277. 



714 DESCRIPTION AND TREATMENT OF INSANITY. 

as an amorphous body, without any distinctive histological 
features. 

, In a communication made to the Societe medico-psycliolo- 
gique, M. Luys ' discusses the subject of the patho-anatomy 
of general paralysis, an affection which he regards as a dif- 
fused interstitial sclerosis of the neuroglia of the nervous 
centres. According to the view he announces, sclerosis acts 
here exactly as it does when it is the distinguishing charac- 
teristic of other affections of the nervous system, or when it 
involves other tissues — that is, it causes an atrophy and dis- 
appearance of the true nerve elements. In a preparation 
which he submitted, the cells had become bodies of vague- 
ly pyramidal form, without distinctive morphological fea- 
tures. 

The nerve-fibres of the cortex are deformed and atrophied ; 
they undergo fatty degeneration, and the nervine escapes into 
the surrounding tissues. 

The neuroglia is probably always increased in cases of 
general paralysis. Rokitansky regarded this as the essential 
feature of the disease, and Luys, in the communication cited, 
advances this view with a cogency and amount of evidence 
that would appear to place the question beyond much doubt. 
The conclusions he arrives at are : 

" That the lesion of general paralysis consists of a general- 
ized hyperplasia of the connective tissue, of which the ele- 
ments are infinitely developed, and that it constitutes for the 
nerve-tissue a condition not essentially different from that of 
cirrhosis of the liver. These lesions appear to have different 
foci of origin, according to the region invaded. Sometimes 
they begin in the white substance, sometimes in the gray cor- 
tical tissue, at others in the submeningeal regions, and again 
in some part of the spinal cord, before making their appear- 
ance in the brain. It is thus that the existence of general 
paralysis is sometimes first revealed by disturbances in the 
motor functions of the spinal cord or medulla oblongata, be- 
fore there is any manifestation of brain symptoms." 

The white substance undergoes changes similar in general 
character to those met with in the cortex — there are like 
changes in the vessels, there is a proliferation of the connec- 
tive tissue, but, on account of the comparatively larger quan- 

1 " Anatomie path ologi que de la paralysiegen6rale," -4 fifths medico-psycTiolo- 
giques, juillet, 1877, p. 106. 



THE PATHOLOGY AND MOEBID ANATOMY OF INSANITY. 715 

tity of this tissue in the white than in the gray tissue, the con- 
sistency is increased instead of being diminished. 

In regard to the other parts of the brain — the island of Reil, 
the optic thalamus, the corpus striatum, the medulla oblon- 
gata, the pons Varolii, the cerebellum — changes, similar to those 
which occur in the cortex are met with, though not probably 
to the like extent. Moreover, the nuclei of the cerebral nerves, 
and the nerves themselves, especially the olfactory, as Voisin 
has shown, undergo inflammation and softening, or sclerosis. 
The existence of like lesions in the posterior columns of the 
spinal cord, and in other anatomical regions of this centre, is 
also a feature of many cases. 

MM. Bonnet and Poincare 1 regard general paralysis as be- 
ing primarily a vaso-motor affection, with its origin in the 
sympathetic system. They deny the existence of any condi- 
tion of the brain which can in the least degree be assimilated 
to sclerosis, that the lumen, even of the smallest vessels of the 
cortex, is ever obscured, or that there is any defect of nutri- 
tion due to the impermeability of the vessels. They admit 
that many cells of the cerebrum, especially of the frontal 
lobes, contain fatty granulations, and that here and there are 
reddish-brown patches, probably consisting of extravasations 
of blood. These changes, however, they regard as secondary 
to the degenerations existing in the sympathetic ganglia. The 
nerve-fibres, both of the gray and white substance, they have 
never found altered, nor have they ever found any evidences 
of sclerosis in the spinal cord. These views are merely cited 
in outline in order to show that there is a marked difference 
of opinion on the subject of the patho-anatomy of general pa- 
ralysis. It is scarcely necessary to say that they are not en- 
tertained by any other pathologists, so far as I am aware. It 
is, however, quite probable that the very initial point of gen- 
eral paralysis is in the sympathetic system, and that, like 
many other forms of insanity, it is in the beginning a vaso- 
motor disorder. Eventually, however, the brain lesions pre- 
dominate over all others, and constitute the essential charac- 
teristics of the disease. 

Mpileptic Insanity. — In post-mortem examinations of per- 
sons dying while the subjects of epileptic insanity, the lesions 
met with are those which are common to simple epilepsy. 

1 "Kecherches sur l'anatomie et la nature de la paralysie generate," Paris, 
18T6. 



716 DESCRIPTION AND TREATMENT OF INSANITY. 

They may consist of morbid growths of various kinds in the 
brain or in the cranium, and by their contact with the brain 
causing irritative adhesions of the membranes to each other 
and to the cranium, or surface of the brain, diseases of the 
blood-vessels, fractures of the cranium and consequent injury 
of the brain, foreign bodies, such as bullets, in the brain, and 
almost every other possible morbid condition. Yery often no 
lesion is found. 

The immediate cause of a paroxysm is a vaso-motor dis- 
turbance either of the nature of a spasm or of a paralysis, by 
which, in the one case, a state of cerebral anaemia is produced, 
and in the other, one of cerebral hyperemia. Probably, in 
those cases in which there are violent fury and excitations to 
acts of violence, the condition is hypersemia, while in those 
characterized by a quiescent state of mind, attended with the 
tendency to mental automatism, intracranial anaemia exists. 

In puerperal insanity the patho-anatomical feature is 
quite surely congestion, in that form which immediately suc- 
ceeds child-birth, and this view is expressed by Yoisin, and 
is sustained by the data supplied by numerous post-mortem 
examinations. In one case, that of a woman who died during 
her third attack, there had been religious mania, with intense 
excitation and incoherence. The autopsy showed the exist- 
ence of many punctai vasculoso3, and a hyperaemic state of the 
optic thalami and of all the central portions of the cerebrum. 
The parietal convolutions exhibited in the perivascular sheaths 
of their vessels numerous masses of fat-molecules and of pig- 
ment. Like aggregations were found in the optic thalami. 

In other cases, the meninges of the spinal cord, as well as 
those of the brain, are in a congested or inflamed condition. 
In those cases of the disease in question which occur during 
or soon after the termination of nursing, an anaemic state of 
the brain is discovered. But, when ensuing on the sudden 
cessation of lactation, the symptoms indicate cerebral hyper- 
emia ; and such is the state found on post-mortem examina- 
tion. 

The views propounded by Sir James Simpson, and which 
have already been alluded to, that puerperal mania is the re- 
sult of uraemic intoxication, and the opinion expressed by 
others that it is a septic disorder, are not sustained by the ex- 
perience of those who have seen many cases of the disease. 
Indeed, the facility with which recovery takes place is of it- 



THE PATHOLOGY AND MORBID ANATOMY OF INSANITY. 717 

self a strong argument against the correctness of either hy- 
pothesis. 

Pellagrous Insanity. — Gintrac x says that in cases of per- 
sons dying of pellagra the brain is rarely found in a normal 
condition ; it is frequently in a state of congestion on the 
surface, and often softened. The membranes are the seat of 
hyperemia. Billod 2 states that no other lesions different 
from those found in ordinary cases of insanity are met with 
than a softening of the white substance of the spinal cord. 

Choreic Insanity. — In the insanity which sometimes ac- 
companies chorea, I am led by the attendant phenomena to 
consider the intracranial condition as one of hyperemia, 
affecting mainly the ideational and psycho-motor centres. 
This, however, is only a hypothesis, as I am not acquainted 
with the results of any post-mortem examinations made with 
special reference to the state of the brain in the affection in 
question. Fatal cases of chorea have, however, occurred, and 
post-mortem examinations of them have been made ; and in 
many of these instances the brain was found to be in a state 
of intense congestion. 

Thus, Dr. John W. Ogle, 3 in sixteen fatal cases of chorea, 
found congestion of the brain and its membranes in some, 
while in others like conditions existed in the spinal cord. 

Fourteen fatal cases were analyzed by Dr. Hughes, and in 
all but four of these there were intracranial congestion and 
other structural changes, such as softening opacities and ad- 
hesions. And in seven fatal cases collected by Romberg 4 
there were softening and degeneration of various parts of the 
brain and spinal cord. 

1 "Nouveau dictionnaire de medecine et de chirurgie pratiques," Paris, 1878, 
t. xxvi, art. " Peilagre," p. 447. 

2 "TraitS de la peilagre," Paris, 1870, p. 192. 

3 " Keniarks on Chorea, Sancti Yiti, including the History, Course, and Ter- 
mination of Sixteen Fatal Cases," British and Foreign Medico- ChirurgicaZ Re- 
view, January, 1868, p. 208. 

" Digest of One Hundred Cases of Chorea," Guy^s Hospital Reports, vol. iv, 
1846, p. 360. 

4 "Lehrbuch der Nervenkrankheiten," Band ii. 



718 DESCRIPTION AND TREATMENT OF INSANITY. 

CHAPTER XIII. 

THE TREATMENT OF INSANITY. 

Before proceeding to discuss the medical treatment of 
cases of insanity, there is a point which requires to be first 
disposed of, for it is one that is suggested both to the phy- 
sician and the patient's friends at a very early period in the 
course of the disease, and that is the question : 

Shall the insane person be treated at home or in an 
asylum % 

A few years ago there would have been but one answer to 
such a question, either from the physician or the friends of 
any patient having the means wherewith to be maintained in 
a hospital specially set apart for the care and treatment of 
those so unfortunate as to be the subjects of mental derange- 
ment ; and for those not having the means, efforts would 
have been made to procure their admission into a like in- 
stitution supported at the public expense. But the case is 
very different now. All are anxious to keep their mentally 
deranged patients or friends at home so long as this can be 
done with safety, and matters are fast reaching that point, in 
some sections of the country, at which no lunatics except 
those who are dangerous to themselves or others will be sent 
to asylums so long as they have friends able to take care of 
them. 

But, before proceeding to consider the reasons for this 
extraordinary change of professional and lay opinion, it is 
proper, in the first place, to ascertain, as far as practicable, 
what forms of insanity require asylum treatment, and what 
forms do not. 

All the varieties of insanity given in the table of classifica- 
tion on pages 292 and 293 can, with reference to this point, 
be arranged into three groups : 

1. Those the subjects of which should never, under any 
circumstances, be forcibly deprived of their liberty by being 
committed to a lunatic asylum against their will. 

2. Those forms a minority of the subjects of which may 
require to be. committed to an asylum. 

3. Those forms a majority of which may require to be so 
committed. 

There is no form of insanity known to alienists all the 



THE TREATMENT OF INSANITY. 719 

subjects of which imperatively require the treatment and re- 
straint of an asylum. 

1. The forms embraced in the first group are included in 
the class of perceptional insanities, comprehending the forms 
of illusions and hallucinations ; the form of intellectual sub- 
jective morbid impulses, in the class of intellectual insanities ; 
and the form of aboulomania, or paralysis of the will, in the 
class of volitional insanities. 

There is nothing in pure, uncomplicated cases of any of 
these forms of mental derangement which requires the treat- 
ment of a lunatic asylum, or which would warrant any inter- 
ference with the full rights and privileges of the individual. 
On the contrary, forcible confinement in such an institution 
would tend strongly to cause the disease to pass into some 
more intense form. The subjects of these varieties of insanity 
are perfectly aware of their morbid condition, and they gen- 
erally look forward with horror to a possible termination 
within the walls of an asylum. 

2. The forms embraced in this group are intellectual ob- 
jective morbid impulses, in the class of intellectual insanities ; 
emotional monomania, emotional morbid impulses, simple 
melancholia, hysterical mania, and epidemic insanity, of the 
class of emotional insanities ; volitional morbid impulses, of 
the class of volitional insanities ; katatonia, primary demen- 
tia, secondary dementia, and senile dementia, of the class of 
compound insanities ; and puerperal insanity and choreic in- 
sanity, of the class of constitutional insanities. 

Of these groups, it may be that, in the forms of intellect- 
ual objective morbid impulses, emotional morbid impulses, 
and volitional morbid impulses, the tendency is toward the 
perpetration of some act of violence. If such is ever the case, 
even in a single instance, the safety of society, as well as the 
good of the individual, requires that he or she should be 
placed under restraint of some kind. A few cases of emo- 
tional monomania exhibit traits which are prejudicial to the 
welfare of society, but the majority are harmless, and should 
not be subjected to any more forcible restraint, if any is nec- 
essary, than that which can be imposed by their physician 
and friends. Simple melancholia is rarely an unmanageable 
affection, and the subjects of hysterical mania seldom require 
to be confined in an asylum. Epidemic insanity is generally 
easily managed at home, as are also katatonia and all the va- 



720 DESCRIPTION AND TREATMENT OF INSANITY. 

rieties of dementia. Very few cases of puerperal or choreic 
insanity require the restraint of an asylum. 

3. Of the third group, most of the cases of intellectual 
monomania with exaltation, intellectual monomania with de- 
pression, chronic intellectual mania, reasoning mania of the 
class of intellectual insanities ; melancholia with delirium, 
melancholia with stupor, hypochondriacal mania of the class 
of emotional insanities ; acute mania, periodical insanity, hebe- 
phrenia, circular insanity, and general paralysis of the class 
of compound insanities ; and epileptic insanity of the class of 
constitutional insanities, require to be restrained wholly or in 
part. 

But the opinions here expressed refer to individuals so 
situated as not to be able to command what they and society 
require — who either do not have the advantages of a home, 
friends able and willing to take care of them, or such medical 
advice and assistance as their cases require. If all these mat- 
ters can be secured, there is no reason why any lunatic, no 
matter under what form of insanity he may suffer, should be 
committed to a public insane asylum. There may be reasons 
why he should not be kept at home, and then he should be 
sent to some one of the private institutions, the superintend- 
ent of which, finding it to his interest to take care of those 
committed to his charge, devotes his time and attention and 
skill to his patients, instead of giving all these to looking 
after farms and manipulating legislatures. Or, if restraint be 
required, the law should be so altered as to allow some friend 
or relative, under bonds and subject to proper inspection, to 
take the charge of the lunatic, and to place him in such re- 
straint as may be necessary to prevent him committing an 
act of violence against himself or others, or his own property 
or that of others. Under such circumstances, public asylums 
— and by public asylums I mean those supported by the cities, 
counties, or States in which they are situated — would only be 
necessary, first, for those who have no money, and, second, 
for those who have no friends. And even the latter class, if 
having money, could readily, under the direction of some 
discreet person appointed by the proper authority, have the 
advantages of treatment in a private institution or in their own 
houses. Then the only persons for whom the asylums would 
still be imperatively required would be those so deplorably 
situated as have neither money nor friends. Unfortunately 



THE TREATMENT OF INSANITY. 721 

there are, and probably always will be, many such. I am 
aware that there are some excellent public asylums, in which, 
as I know of my own knowledge, the treatment is skilful and 
humane, in which the medical officers take a pride in their 
work, and in which the inmates are as tenderly cared for as 
though they paid the highest prices for their board, and had 
the most powerful individuals for their friends. But to-mor- 
row, at the behest of a governor, or legislature, or other po- 
litical body, they may be ousted from their positions to make 
way for some medical adventurer who has rendered impor- 
tant services to the " party." Such acts are of common occur- 
rence. 

Again, the system of inspection of such institutions, when 
there is any at all, is so inefficient that the greatest abuses 
may spring up, and the world be none the wiser, till some 
day an exposure takes place ; and then it is discovered that 
an asylum which has been the pride of the^community is in 
reality a hot-bed of neglect and cruelty. A legislative inquiry 
is ordered, a condemnatory report is made, but, through "po- 
litical influence," it is smothered, and things presumably go 
on as before. Till the public asylums are organized upon the 
same general principles as are other hospitals, things are not 
likely to be better than they are now. As I said 1 several 
years ago, in a paper read before the Medical Society of the 
State of New York, "Each should have its corps of visiting 
physicians and surgeons, and its residents, instead of being 
placed under the control of one man, whose multitudinous 
duties with legislatures, visitors, farms, and other non-medical 
matters, prevent him giving the proper time and attention to 
his specific obligations. By this plan, to an asylum with six 
hundred patients there would be a medical board of at least 
twenty members — and the number could be increased as occa- 
sion required — besides a dozen or more of young physicians 
living in the institution and carrying out the orders of their 
seniors." 

It may be objected against the home treatment of persons 
the subject of mental aberration that no care which could be 
exercised could prevent acts of violence. Such an objection 
would probably be of force in some cases, but are things any 
better in the public asylums ? When we look back over the 

1 "The Non-Asylnm Treatment of the Insane," Transactions of the Medical 
Society of the State of New Yorlc, 1859. 
46 



722 DESCRIPTION AND TREATMENT OF INSANITY. 

last four or five years only, and bring to mind the long list 
of the murders, the suicides, the acts of incendiarism, which 
have been committed, we see what few advantages, even on 
the score of safety, such institutions offer. Even while these 
pages are going through the press, we get the account of a 
poisoning, in a public asylum, by one lunatic of a dozen 
others, five of whom died in a few minutes. The number of 
acts of violence committed in public asylums during the last 
five years is many fold greater than that perpetrated by all 
the lunatics whose condition has been recognized, and who 
have been under the care of their friends or in some private 
institution for the insane. 

In conclusion, I have to express the opinion that no insane 
person who can be properly cared for at home, in the way of 
medical attendance and nursing, or who can be placed in a 
private, or what may be called a " family asylum," should be 
committed to a public institution for lunatics. Several years 
ago I ' wrote as follows, and subsequent experience has not 
only tended to confirm the correctness of the view^s then com- 
municated, but has caused me to carry them to the point now 
stated : 

"It is not always necessary to confine him (the lunatic) in 
an asylum, but it is necessary, in the great majority of cases, to 
place him in such a situation as will secure for him safety, the 
companionship of sensible people, and the influence and con- 
trol of some one skilled in the philosophy of the human 
mind, in the anatomy and physiology of the brain and ner- 
vous system, and in medical science generally. The great 
difficulty with asylums is, that they contain only insane peo- 
ple, and the prevalent idea among the public (and it is often 
carried out by the officers of the asylums) is, that institutions 
for the insane are simply places where dangerous or trouble- 
some maniacs are kept in safety. My own idea is, that the 
best of all places for a lunatic of any kind is the family of a 
physician— of such a one as I have just mentioned. The asso- 
ciation of an insane person day after day, year after year, 
with others similarly affected, with scarcely the least contact 
with people of sound minds, is certainly in opposition to the 
first principles of scientific medicine." 

Now, it may be asked, What "companionship with sen- 

1 " A Treatise on the Diseases of the Nervous System," sixth edition, New 
York, 1876, p. 375. 



THE TREATMENT OF INSANITY. 723 

sible people" has the lunatic immured within the walls of an 
asylum, without the right to see his friends or even his phy- 
sician ; without even the privilege of writing to them, .or to 
those having authority to correct abuses, if there are any such 
officials \ What " control of some one skilled in the philoso- 
phy of the human mind," etc. % Even if the superintendent 
be such a person — and many of them, I am happy to say, are 
accomplished and scientific physicians and gentlemen — the 
other duties which fall to his lot prevent his having any inti- 
mate acquaintance with those under his charge. 

But, when — as is, I regret to say, sometimes the case — the 
superintendent, appointed through political influence, not for 
his medical knowledge, but for the services he has rendered to 
his party organization, is ignorant of the first principles of the 
human mind, to whom the anatomy and physiology of the 
brain is a sealed book,, and whose knowledge of insanity has 
no deeper, basis -than occasional facetious conversations with 
the village fool, it is a terrible thing for the poor wretches who 
have to live under his dominion. 

Again, under the system which at present exists in many 
of the public asylums of this country, the attendants are usu- 
ally selected, from the lowest and most brutal class of the 
population; \ They are the henchmen who, having been ever 
ready to fight for their leader — or " boss," as he is called in 
the political slang of the day — are also rewarded by being 
appointed to situations in lunatic asylums. To expect such 
individuals, whose instincts are hot so mild and decent as 
those of a well-trained dog, to forget their natural and ac- 
quired savageism, and to act in a manner approaching that of 
an average human being, would betray a confidence in the re- 
formatory influence of the American public lunatic asylum, as 
it sometimes exists, which, I am sorry to say, personal knowl- 
edge forbids me to share. It is no matter for surprise, there- 
fore, to learn, as we do every now and then from the reports 
of legislative committees of inquiry, that the patients ' ' are 
cruelly gagged, and beaten, and ducked, and ill-fed, and 
scantily clothed, and 'taken down' and 'spread-eagled' (the 
technical names for inhuman punishment), and over-worked, 
and subjected to various needless punishments of revolting 
severity, and become the victims of inexcusable neglect, and 
in many cases left in their last moments with no hand to 
administer to their dying wants"; or to learn that in one insti- 



724 DESCRIPTION AND TREATMENT OF INSANITY. 

tution a " patient was beaten to death by an attendant"; or 
that in another a patient who refused to eat " was caught and 
laid on a bench ; one attendant held his hands and sat across 
his body; another attendant and a patient helped to hold him; 
his mouth was plugged to prevent his closing it. The food 
(soup) was poured in from a pitcher, his breath was heard to 
c gurgle ' as it went into his wind-pipe, and in five minutes he 
was dead." Or that, in another, one of the keepers carried a 
harness-strap with a buckle on the end of it, and that patients 
were beaten with the buckle-end, and that the same keeper 
knocked patients down with a bunch of keys ; and that an- 
other knocked a patient down, jumped on him, and kicked 
him till he had fits. Such things do not surprise those of us 
in this country who have studied the system, and know of 
what it is capable. -There are lunatic asylums here which are 
in all respects as good, and in many respects better, than any 
institutions of the kind in the world ; there are others worse 
than any to be found in a civilized country, and in which 
abuses exist to which no other people but the patient and 
long-suffering American would for a moment submit. 

The. means of treatment of the insane, in or out of, an asy- 
lum, may be advantageously divided into four classes — the 
mechanical, the moral, the hygienic, and the medicinal. 

The Mechanical Treatment. — The first point under this 
head which requires consideration is in regard to the means to 
be adopted to prevent a lunatic with tendencies to violence 
from inflicting injuries on himself or others, or damaging 
property about him. This involves the question of non-re- 
straint, and it is one that deserves more than a mere passing 
notice in a work intended mainly for the use of physicians in 
a country where the principles of Pinel and Conolly have as 
yet only a limited footing. 

In 1792, Pinel was appointed chief physician of the Bi- 
cetre, the great lunatic asylum for pauper men in Paris. 
He found that all the most violent cases were habitually kept 
chained. He struck off their irons, substituted kindness for 
blows, improved their diet, and so ameliorated their condi- 
tion in other respects that many who were regarded as in- 
curable were restored to the world with their mental facul- 
ties again to guide them. This was the first grand step 
toward treating a lunatic somewhat in accordance with the 
methods employed with rational individuals. 



THE TREATMENT OF INSANITY. 725 

But PinelV methods appear to have sprung more from 
goodness of heart than from any therapeutical principle ; and, 
though knocking off the manacles from the maniac's limbs, he 
still continued to employ in some cases milder methods of 
mechanical restraint. It was reserved for Dr. Conolly, an 
Englishman, in 1839, to demonstrate to the world that there 
was no antagonism between humanity and science in this 
matter, and that those methods of management which were 
most kind and gentle were at the same time the most effica- 
cious as curative agents. It is true that for two or three 
years previously the doctrine of " non -restraint " had been 
advocated and practiced to some extent at the York Retreat 
and Asylum, under the charge of the Friends, but it had 
made little headway till Conolly, at the Han well Asylum of 
London, not only took away every form of apparatus calcu- 
lated to confine the lunatic's body or limbs, but wrote and 
spoke so eloquently and logically in support of his views that, 
before long, they came to be recognized as correct in most 
parts of the civilized world, the only notable exception being 
the free and enlightened United States of America, f, When 
Dr. Conolly took charge of Hanwell, there were closets full of 
instruments of restraint, which the attendants were allowed to 
use at their pleasure. There were strait- waistcoats, " restraint 
chairs," muffs, leg-locks, various kinds of complicated ap- 
paratus, straps of different varieties, and even chains. They 
do not appear to have had the " crib, "that appliance so dear 
to the hearts of some of our American superintendents. The 
epileptics, over one hundred in number, were every night 
fastened by one hand to their bedsteads ; and, in addition, 
there were over forty patients kept constantly in some form 
of mechanical bondage night and day. In his first report, 
Dr. Conolly said, in speaking of the forcible restraint which 
he found practiced when he took charge of the institution, 
" that it was in fact creative of many of the outrages and dis- 
orders, to repress which, its application was commonly deemed 
indispensable, and, consequently, directly opposed to the chief 
design of all treatment — the cure of the disease." 

But Dr. Conolly began very cautiously with his measures 
of reform, and did not at first dispense with every kind of 
mechanical restraint. For those patients who were continu- 

1 Portions of this sketch are taken from a paper by the author on " The 
Treatment of the Insane," in the International Review for March, 1880. 



72G DESCRIPTION AND TREATMENT OF INSANITY. 

ally making efforts to take off their clothes, strong dresses 
were provided, which were secured around the waist by a 
leathern belt, fastened by a small lock ; and the covering for 
the feet consisted of warm boots, similarly arranged. For 
those who were disposed to strike or otherwise injure others, 
to tear the bedclothes, etc., a dress, of which the sleeves ter- 
minated in a stuffed glove without divisions for the fingers 
and thumb, was provided. " But there was no form of strait- 
jacket, no hand-straps, no leg-locks, nor any contrivance 
confining the trunk or limbs or any of the muscles," and all 
the restraint chairs were removed from the wards. During 
the following year, even these mild forms of restraint were 
taken away, and then Dr. Conolly enunciated a proposition, 
the truth of which is entirely established, and which is ap- 
plicable to any lunatic asylum in any country, that "any 
contrivance which diminishes the necessity for vigilance 
proves hurtful to the discipline of an asylum." x 

This may be considered the starting-point in the theory 
and practice of non-restraint, as it is carried out in Great 
Britain, Germany, and other parts of the civilized world. 

Now, let us take a brief review of the treatment of lunatics 
as regards mechanical restraint in this country. While it is 
certainly true that there are lunatic asylums the superintend- 
ents of which are actuated by a desire to keep the number of 
restraint cases at a minimum, there are only two public insti- 
tutions — the Kings County Asylum at Flatbush, Long Island, 
under the charge of Dr. Shaw, and that at Athens, Ohio — in 
which mechanical restraint in some form or other is not em- 
ployed ; and in some the proportion equals that at Han well 
before Dr. Conolly instituted his reform measures. 

Now, I am not an advocate of absolute non-restraint under 
all possible circumstances and conditions. There are cases 
in which it may be indispensably necessary to preserve the 
life or secure the comfort of the patient. It is never necessary 
to secure the lives or the comfort of others, and, when used, 
it should be with all the safeguards against abuse, which 
sound policy and humanity dictate. Being requested by a 
recent investigating committee of the Senate of the State of 
New York to make such suggestions as I might deem proper 
in regard to the future management of the insane asylums 

1 " The Care and Cure of the Insane, being the Reports of the ' Lancet ' Com- 
mission on Lunatic Asylums, 1 ' by J. Mortimer Granville, M. D., London, 1877. 



THE TREATMENT OF INSANITY. 727 

of the State, I stated, among others, the following proposi- 
tion : _ 

" It shonld not be allowable for any one but a medical 
officer of an asylum to order a patient to be placed in me- 
chanical restraint or in seclusion, and even then a record of 
such instance should be kept in a book provided for the pur- 
pose. This book should always be open to the inspection not 
only of officials in authority, but to the counsel and family 
physician of the patient, and it should clearly show in detail 
the reason for the use of such restraint or seclusion 

" At present ignorant and brutal attendants, some of them 
selected from the very lowest class, can, at their option, from 
whim, caprice, anger, or any other inadequate cause, order or 
place a lunatic in the camisole, crib, or other mechanical re- 
straint. There are many instances on record of serious bodily 
injury and even death having been produced by mechanical 
restraint improperly applied, to say nothing of the deleterious 
effect caused on the mind of the patient by such procedure." 

These principles appear to be carried out in that excellent 
institution, the Illinois Eastern Hospital for the Insane at 
Kankakee, under the superintendence of Dr. Dewey, in which 
it is stated 1 that : 

u The amount of restraint has constantly diminished under 
the methods employed. The instances in which it has been 
used on each side, respectively, in the year ending September 
30, 1882, could be counted on one's fingers and thumbs — ten 
times in all on the female side, and six in all in the male 
division." And this with an average daily population of over 
three hundred and eight. 

There are other insane asylums in the country, notably 
the one at Athens, Ohio, which could make probably as good 
a showing as this ; but, when we find the superintendents as 
a body setting themselves against reform in the excessive 
and indiscriminate use of mechanical restraint, there is little 
chance of general improvement till many of the present race 
are weeded out by time, and their places filled by more scien- 
tific and progressive men. 5 

1 "Third Biennial Report," 1882, p. 23. 

2 Tims, at a meeting of the Association of Superintendents, held a few 
years ago, the president, Dr. Walker, gravely told his fellow-members that he 
supposed, if anything had been settled to the satisfaction of members of the 
Association, it is that, in. this country, our patients, by original temperament 



728 DESCRIPTION AND TREATMENT OF INSANITY. 

If restraint be used, the only forms allowable should be 
leathern mittens, locked to the wrists, to prevent the patient 
tearing the clothing, and other articles of locked clothing. 
But, as attendants become more accustomed to the duty of 
reasoning with the insane, the use even of these measures can 
be reduced to a minimum — not yet reached in our best asy- 
lums — or, perhaps, altogether dispensed with, as at Flatbush, 
New York, ? and Athens, Ohio. 

Forcible Alimentation. — In those patients who will not eat, 
means must be taken to secure their nourishment by the com- 
pulsory ingestion of food. In some extreme cases, in which 
there is great physical weakness, this must be done by injec- 
tions of nutritive substances into the rectum ; in others, the 
food must be introduced through the oesophagus. Many pa- 
tients, who at first refuse to swallow food, can be induced to 
do so by persuasion. At other times, though they may refuse 
to one nurse, they will readily accede to the request of an- 
other, whom they like better ; and, again, it is only some 
particular kind of food they refuse, or they wish, under the 
delusion that it is poisoned, to submit it to some test that 
they have devised. I had a patient once who would never 
eat or drink anything till he had placed the vessel containing 
the food or drink in the sunlight, or, if this could not be 
obtained, near the register by which the heat entered the 
room. In all such cases it is better to yield to the whim of 
the patient than to resort to force. If this, however, should 
be necessary, it should never be left to an attendant, but 
should be employed by a physician. 

The practice, recommended by Guislain, 2 and carried out 
in some asylums, of forcing open the mouth, closing the nos- 
trils, and pouring liquid food down the throat, is one that 
should never, in my opinion, be employed. It has resulted 

or by some inherent quality of the universal Yankee, will not submit to the 
control of any person they consider their equal or inferior so readily as to that 
of mechanical restraint. And another member,, Dr. Compton, said: "I think 
an asylum cannot be found in this country, where the- first thing a boy learns 
to read is the Declaration of Independence, and where every youngster learns 
that he is in l the land of the free and the home of the brave,' in which restraint 
will not be necessary." 

1 "• Non-Restraint in the Treatment of the Insane," and "A Second Year's 
Experience with Non-Restraint in the Treatment of the Insane," Archives of 
Medicine, February, 1881, and April, 1882. 

2 " Lecons orales sur les phrenopathies," Gand, Paris, 1880, t. ii, p. 240. 



THE TREATMENT OF INSANITY. 729 

in death by strangulation, and almost always causes more or 
less choking. 

The better plan is, after having secured the patient so that 
resistance is impossible, to force the mouth open with a screw 
wedge, and then, the head of the patient being thrown well 
back and kept fixed, to introduce the gag, made of smooth 
wood, with a hole in the centre. Through this hole a large- 
sized stomach-tube is introduced and carried into the oeso- 
phagus. The food, which of course is liquid or semi-liquid, 
should then be poured into the funnel-shaped upper extrem- 
ity of the tube, when it readily passes into the stomach. Or 
the stomach-pump may be used, and the food introduced by 
its means directly from the vessel in which it is contained. 
The pump, however, has the objection of requiring the inges- 
ta to be absolutely liquid, to avoid obstruction of the valves. 

The introduction of a tube through the nostril has been 
recommended, but its use is not satisfactory, on account of 
the smallness of calibre required, and which prevents any but 
very thin food from being given. 

There is nothing in the forcible alimentation of the insane 
different from the feeding, through tubes, frequently neces- 
sary in those cases of disease in which the patient is unable 
to swallow, except in the one point that force is often re- 
quired. This should be overwhelming and promptly applied, 
so as to prevent, as far as possible, the struggles and conse- 
quent bruises or other injuries that may be received. 

Moral Treatment. — One of the most important means com- 
ing under this head is rest. With some patients it is impos- 
sible to secure the mental repose required by any efforts they 
are able to make ; in the cases of others, however, great assist- 
ance may be obtained through the intelligent co-operation of 
the affected individual. Instances in which the reasoning 
faculties are so far destroyed as to make it a matter of im- 
possibility to be aided by the patients are rare. The diffi- 
culty is to discover the way to the light — mere glimmer as it 
may be — which exists ; and even when this is done, skill in the 
endeavor to develop it is of almost equal importance. There 
are no rules which can be laid down in regard to these mat- 
ters which are of equal applicability in all cases. Some per- 
sons have an inborn adaptability by which they readily ob- 
tain an influence over all with whom they come in contact. 
Others, with the best intentions in the world, never succeed 



730 DESCRIPTION AND TREATMENT OF INSANITY. 

in ingratiating themselves with those about them. Patience 
and tact are probably, in such cases, as indispensable qualities 
as can be possessed. Without them, all the knowledge that 
can be acquired in a lifetime will be of but little avail. 

Works on insanity written by superintendents of lunatic 
asylums generally recommend that, for the procurement of 
the rest which the racked and wearied brain often so impera- 
tively demands,, the patient should, at as early a date as pos- 
sible, be remove\l to an institution for the insane.^ As the 
word asylum is ordinarily understood, I have no hesitation in 
declaring it to beiny deliberate conviction that this is, inmost 
cases, the worst possible thing that can be done. . Circum- 
stances may be such that, in cases of persons suffering with 
some acute form of insanity accompanied with 'tendencies to 
violence, some place where the lunatic can be kept in safety 
is absolutely requisite, and the asylum at once suggests it- 
self. But, if the patient can, even in such a form of the dis- 
ease, have careful nursing, skilled medical attendance, and iso- 
lation in his own house, or, better still, in the house of some 
physician, who pays special attention to the subject, he will 
have all the advantages in the way of rest which the best 
asylum in the land can give him. If these cannot be secured, 
then send him to the best asylum available. 

This subject has already been discussed in other relations, 
but a few words more in regard to it in this connection appear 
to be advisable. 

It has just been said that in those works on insanity writ- 
ten by medical officers of asylums, the earliest possible de- 
portation of the patient to such an institution is recommended 
as an indispensable matter. There are some, however, who 
look at the matter in its true light, and who, hence, make 
other recommendations. 

Thus, Maudsley 1 says : 

" The principle which guides the present practice is that 
an insane person, by the simple warrant of his insanity, shall 
be shut up in an asylum, the exceptions being made of par- 
ticular cases. This I hold to be an erroneous principle. The 
true principle to guide our practice should be this : that no 
one, sane or insane, should ever be entirely deprived of his 
liberty unless for his own protection or the protection of so- 
ciety. . . . 

1 " The Physiology and Pathology of the Mind," London, 1867, p. 424. 



THE TKEATMENT OF INSANITY. 731 

"Is it not a common thing to hear from an insane person 
bitter complaints of the associations which he has in the asy- 
lum, and of the scenes of which he is an unwilling witness — 
scenes which cannot fail to occur, notwithstanding the best 
classification, where all sorts and conditions of madness are 
congregated together ? What, again, can be considered more 
afflicting to a man, who has any intelligence left, than the vul- 
gar tyranny of an ignorant attendant — a tyranny which the 
best management cannot altogether prevent in a large asylum \ 
And I might go on to enumerate many paore of the unpre- 
ventable miseries of life in an asylum which, when superin- 
tendent of one, forced themselves painfully on my attention, 
and often made me sick at heart." 

And more recently the same author ' says : 

u The grave and anxious question in a particular case is, 
whether an asylum is necessary or not. The accepted no- 
tions regarding insanity not many years ago we're : first, that 
the best means to promote the recovery of a patient who was 
laboring under it was to send him to an asylum ; and, sec- 
ondly, that, so long as he was insane, there was no better place 
for him than an asylum. These opinions had been urged so 
persistently, and held so long, that they had become a habit 
of thought which was deemed by some to have the authority 
of a law of nature. Opinion has now, however, changed so 
much that the question which first occurs to the mind is, 
whether it is possible to treat the patient out of an asylum. 
The decision as to what should be done is often most difficult, 
since social, pecuniary, and legal considerations come in to 
complicate the medical question, and most medical men 
would willingly get rid of the responsibility which it entails." 

Dr. Blaridford, 2 after mentioning former practices, says : 

" Now, from all asylums, patients are sent to the sea-side, 
the theatre, the picture-galleries. [How much of this is done 
in the United States ?] Each proprietor vies with his fellows 
in providing recreation and entertainment for his patients— in 
proving, in fact, how little they need the restraint of an asy- 
lum. There will always be a certain number who cannot be 
allowed so much liberty, who cannot be taken to the sea-side, 
who cannot even walk beyond the bounds of the asylum 
grounds, whose life is one incessant struggle to escape by 

1 " The Pathology of the Mind," New York, 1880, p. 524. 

2 " Insanity and its Treatment," Edinburgh, 1871, p. 370. 



732 DESCRIPTION AND TREATMENT OF INSANITY. 

force or fraud, or execute, perchance, some insane project, 
fraught with danger to themselves or others. Some there 
will be whose limited means procure for them greater luxury 
and enjoyment among the numerous boarders of an asylum 
than could be afforded were they placed alone in a private 
family. But there are many, with ample means — patients who 
make the fortunes of asylum proprietors — whose lives would 
be infinitely happier did they live beyond asylum walls." 

Dr. Dickson ' says : 

'" As a matter of principle, I should strongly recommend 
that a patient should never be sent to an asylum if such a 
course can be' avoided. There is no law prohibiting the treat- 
ment of a patient at home. The lunatic is not a criminal to 
be put under locks and bonds, and it is only when he dis- 
turbs the public peace, or when by cruel and unusual treat- 
ment other people infringe the law as regards him, that au- 
thority can interfere in his behalf." 

Dr. C. Pinel, 3 while contending for the general principle 
that lunatics should be sequestered, admits that the excep- 
tions are many. " Every rule," he says, " has its exceptions, 
and we should, at least in the beginning, when the disease is 
recent and not of grave character, give the patient the op- 
portunity of remaining in his own house. Thus the subject 
of maniacal excitement, a restricted monomania, a moderate 
degree of melancholia, certain kinds of hallucinations and 
false conceptions not relating to the family, hypochondriacs, 
of dementia, etc., may properly remain at home." 

"In treatment at home," he continues, "if the attentions 
of the relatives are well received, taken at their first value, 
accepted with gratitude, eagerly desired, it would be inhuman, 
indiscreet, and not in accordance with sound medical science, 
to deprive him of them. Nothing can replace, nothing equal, 
the tender devotion, the affectionate solicitude of the family. 
Many times we have been the witness of the inestimable bene- 
fit of these moral and physical aids, and it is for us a sacred 
duty, in the absence of the most imperious necessity, not to 
separate the lunatic from them." 

Dr. Maudsley, Dr. Blandford, Dr. Dickson, and Dr. Pinel 

1 " The Science and Practice of Medicine in Relation to Mind," London, 1874, 
p. 389. 

2 " De l'isolement des alienes," Journal de medecine, mentales, t. i, Paris, 1861, 
p. 80. 



THE TREATMENT OF INSANITY. 733 

are, or have been, superintendents of lunatic asylums. The 
three first are teachers of psychological medicine in prominent 
London medical schools, and hence their ability to speak in- 
telligently on the subject will not, I presume, be questioned 
in any quarter. 

Hence, in regard to the matter of securing rest for the pa- 
tient, the physician must take all the circumstances into con- 
sideration, and assume the responsibility of so acting in the 
matter as the facts appear to dictate. 

If it be decided to send him to an asylum, or away from 
his own home to the custody of a physician, nothing can be 
worse than to inveigle him into going peaceably, by fraud or 
deceit of any kind. To entice him into a carriage under the 
pretence that it is for the purpose of giving him a drive, or to 
take him to see a friend or to a hotel is certainly unjustifi- 
able under any possible circumstances. The deception is one 
which the patient often keenly remembers, and always with 
anger ; it prejudices him against the superintendent or other 
person under whom he is to be placed, and puts him into a 
frame of mind most unpromising for the results of future 
treatment. If he has to go, and will not go quietly on being 
told where he is going, and for what purpose, sufficient force 
should be provided to compel him to go. 

In regard to the question of conversing with a lunatic, and 
humoring or combating his delusions, or morbid fears, or ten- 
dencies, some difference of opinion exists among alienists. 
In former times there was none, and not only arguments and 
threats were administered to the lunatic for the purpose of 
coercing him, but measures of supposed still stronger potency 
were employed. Now these latter are left to the attendants, 
and by them they are only used surreptitiously. 

Less than seventy years ago, a lunatic, named Norris, an 
officer of the British navy, was confined in the great mad- 
house Bethlehem. For a threat of violence against the physi- 
cian, Dr. Haslam, he was subjected to restraint of such a 
character that we wonder now how the mind of a humane phy- 
sician, as Dr. Haslam undoubtedly was, could work out the 
details. An iron collar was put around his neck, another 
broad and strong band of the same material encircled his 
body, his arms were confined in the same manner, and the 
bands around them were united to the one that was fastened 
around the chest. The ankles were fettered, and then the 



73i DESCRIPTION AND TREATMENT OF INSANITY. 

neck collar was connected by a chain six inches long with an 
iron ring which slid np and down on a stont bar fixed to the 
wall at the head of his bed. It was impossible for this unfor- 
tunate wretch to lie down, to stand np, or, in fact, to assume 
any other position than that of sitting on his bed of straw, 
and yet he lived in this way for nine years in a stone cell. 

In Dr. Mead's time, lunatics were beaten as a therapeutical 
measure to quiet them and rid them of their delusions. Cul- 
len recommends the infliction of corporal punishment as an 
effectual means of rendering them rational and of impressing 
them with terror. 

Dr. Haslam, ' while deprecating resort to such harsh meas- 
ures, nevertheless says : 

" In the most violent state of the disease the patient should 
be kept alone in a dark and quiet room, so that he may not 
be affected by the stimuli of light and sound — such abstrac- 
tion more readily disposing to sleep. As in this violent state 
there is a strong propensity to associate ideas, it is equally 
important to prevent the accession of such as might be trans- 
mitted through the medium of the senses. The hands should 
be properly secured, and the patient should also be confined 
by one leg ; this will prevent him from committing any vio- 
lence. The more effectual and convenient mode of confining 
the hands is by metallic manacles, for, should the patient, 
as frequently occurs, be constantly endeavoring to liberate 
himself, the friction of the skin against a polished metallic 
body may be long sustained without injury, whereon excoria- 
tion shortly takes place when the surface is rubbed with linen 
or cotton." 

And this was not all ; the mind was worked upon and tor- 
tured, and deceptions of various kinds were considered proper 
and curative. 

Thus, Dr. Cox 2 says : 

" The conscientious physician, in the execution of his duty, 
attempting the removal of these deplorable maladies, is under 
the necessity of occasionally deviating from the accustomed 
routine of practice, of stepping out of the beaten path, and, in 
some cases that have resisted the usual methods, is warranted 
in adopting any others that promise the smallest hope of suc- 
cess. Thus, the employment of what may be termed pious 

1 " Observations on Madness, 1 ' second edition, London, 1809, p. 289. 

2 " Practical Observations on Insanity," London, 1815, p. 28. 



THE TREATMENT OF INSANITY. 735 

frauds, as when one simple, erroneous idea stamps the charac- 
ter of the disease, depriving the affected party of the common 
enjoyments of society, though capable of reasoning with pro- 
priety, perhaps with ingenuity, on any subject not connected 
with that of his hallucinations, the connection of which has 
resisted our very best exertion, and when there is no obvious 
corporeal disposition, it certainly is allowable to try the effect 
of certain deceptions contrived to make strong impressions on 
the senses by means of unexpected, unusual, striking, or ap- 
parently supernatural agents ; such as often waking the party 
from sleep, either suddenly or by a gradual process, by imi- 
tated thunder or soft music, according to the peculiarity of 
the case ; combating the erroneous deranged notion, either 
by some pointed sentence, or signs executed in phosphorus 
upon the walls of his bed-chamber, or by some tale, assertion, 
or reasoning, by one in the character of an angel, prophet, or 
devil ; but the actor in this drama must possess much skill, 
and be very perfect in his part." 

And by such puerilities, less than seventy years ago, it 
was attempted to cure insanity ! Really, the progress of 
medicine, as well as the advance in the intelligence of the hu- 
man race, has not been slight since that time. 

But, about forty years ago, Leuret, 1 one of the most emi- 
nent mental physiologists the world has produced, proposed 
and carried out a plan of treatment which he called "moral," 
and which has been practiced in this country within the last 
ten or twelve years. It consisted in reasoning with the patient 
relative to the falsity of his delusions, and, if he persisted in 
maintaining them, notwithstanding the arguments adduced, of 
subjecting him to the cold douche on his head and body gen- 
erally till he announced that he was convinced. Shortly af- 
terward he was asked again whether or not he still held to his 
false conceptions, and if there was any hesitation to answer in 
the negative, he got the douche again, and so on till his cure 
was complete. As an illustration of the method, I quote the 
following case from Leuret. 8 Speaking of the method, he 
says : 

"The water failing on. the head and chest produces in 
these parts a glacial oppression ; the lower parts of the body 
and the inferior extremities feel almost nothing. It ?s painful 

1 "Du traitement moral dela folie," Paris, 1810. 
3 Op. cit., p. 187 et seq. 



736 DESCRIPTION AND TREATMENT OF INSANITY. 

to receive, but we have tried it for a longer time than any of 
our patients." 

After having heard a patient, A., speak of his delusions, 
M. Leuret thus addressed him : 

' U A., I am going to tell you now what I think of all that 
you have said. There is not a word of truth in it. All the 
things that you have related are false, and it is because you 
are insane that you are here in. the Bicetre.' 

■ " To this, A. replied : 

" ' Monsieur Leuret, I do not think I am insane. I cannot 
help seeing the light-house, because it is immediately before 
me, nor the persons who are under my bed, nor the caves, for 
they are there. You think that all I have said is false, but I 
know what I see and hear. Now, after what I say, is there 
no hope that you will let me go out of this place ? * 

" 'You can go out, but on one condition. Listen well to 
what I am about to say. You will go away from here only 
when you are no longer insane ; and this is what is necessary 
for you to do to convince me that you are cured : you must 
not look at the sun or the stars ; you must not believe that 
there are caves under your bed, for there are none ; you must 
not believe that you hear voices in these caves, for there are 
no voices, or that there are persons there who speak to you, 
for they do not exist ; you are not the saviour of the king, 
and you must not think that you are watching over his safety. 
You must cease speaking of all these things, because, if you 
continue to do so, I shall have still to regard you as insane. 
And more ; you must never refuse to work, whatever may be 
the kind of labor you are commanded to perform. If you 
wish me to be satisfied with you, you must obey, because all 
that I ask of you is reasonable. Promise me, therefore, that 
you will not any more think of your delusions ; promise that 
you will no longer speak of them.' 

" 'If [replied A.] you say they are delusions, and, there- 
fore, you do not wish me to talk of them, very well, I will 
cease speaking of them.' 

" ' Will you promise not to think of them ? ' 

"The patient hesitated. He was pressed sharply, and 
finally said : 

" ' No, sir, I will no longer think of them.' 

" 'Will you promise to work every day that you are or- 
dered to work ? ' 



THE TEEATMENT OF INSANITY. 737 

" ' I have an estate of my own. I wish to go out to work 
on my own land.' 

" ' I have told you the conditions on which you will be 
allowed to work on your estate. Now, I ask you again if 
you will consent to work ? ' 

" The patient hesitates. 

" ' As you have often broken your word to me [continued 
M. Leuret], and as I cannot depend on your promises, you 
are going to get the douche, and we will continue to give it 
to you every day until you come to us of your own accord 
and ask to be put to work, and until, further, you, without 
any suggestions from us, confess that all the things you have 
been talking about are delusions.' 

"Douche! It is painful to him, and he does not delay 
long to come out. 

" ' You wish me to work. I will. You wish me not to 
think any more of the things of which I have spoken, because 
they are only imaginations, as I well know. To all the peo- 
ple who may speak to me of those things I will say that 
they are not true, but are delusions which I have had in my 
head.' 

" ' Will you go to work to-day % ' 

" ' Since you compel me, I will.' 

" ' Will you go willingly ? ' 

" ' Since you force me, I will.' 

" ' You ought to say that you understand that it is for your 
interest that you should go to work. Do you go willingly, 
yes or no ? ' 

" Hesitation. Douche. After a moment : 

" ' Yes, sir. Everything that I have said to you is a delu- 
sion. I will go to work.' 

" ' You have been a lunatic, then % ' 

" ' No, I have not been a lunatic' 

" ' You have not been a lunatic % ' 

" 'I do not think so, at least.' 

"Douche. 

" ' Have you been a lunatic % ' 

" 'Is a man a lunatic who has imaginations of seeing and 
hearing % ' 

"'Yes.' 

" ' Well, sir, and so that is insanity. There have been no 
women, or men, or companions : all that is insanity. ' 
47 



738 DESCRIPTION AND TREATMENT OF INSANITY. 

"'When you think you hear things of that character, 
what will you say ? ' 

' " 'I will say it is insanity, and I will give no attention to 
them.' 

" ' And that woman who made court to you ? ' 

" 'Sir, that is not true; that is insanity. My head is 
quieter since I have had the douche. All that I said was in- 
sanity, and I no longer think as I did.' 

" 'I wish you to come to me to-morrow and thank me for 
having cured you of your insane ideas.' 

" 'I promise to work, and also to thank you for having 
cured me.' 

"'I want you to work to-day.' 

" 'I will go, I promise you.' 

"The evening of the same day A. had a douche, which 
M. Aubanel gave him [M. Aubanel, it may be stated, was 
one of the medical officers, and is the gentleman to whom we 
are indebted for that highly "moral instrument of persuasion 
the ' crib,'" so much liked by certain of our American super- 
intendents] for not having recollected that he had to work 
that day. He yielded on the second trial. He did not work, 
he said, because he did not know to whom he was to apply 
in order to be enrolled with the workers. M. Aubanel, very 
properly thinking this excuse insufficient, indicated to him 
the overseer, and A. promised to work on the morrow." 

After this a few threats of the douche were sufficient to 
keep the patient free from delusions, and at the end of about 
three months he was discharged cured. 

All this reads very much like the record of the proceedings 
in cases of the question being applied to suspected criminals 
during the middle ages. One method was, that instead of 
pouring the water on the outside of the body to extort con- 
fession, it was poured into the stomach, till the pain caused by 
the distension became unbearable, and the wretch confessed, 
either truly or falsely ; or, if endowed with greater powers 
of endurance than M. Leuret' s patient, persisted in silence. 

An official record reads as follows : 1 

" Stripped, and placed on the little trestle and bound. 

"At the first kettleful, said nothing. 

1 " Les penalites anciermes. Supplices prisons et grace en France ; d'apres 
des textes inedits,"par Charles Desmaze, conseiller de la cour imperiale de Paris, 
Paris, 1866, p. 422. 



THE TREATMENT OF INSANITY. 739 

" At the second, ' Ah, I know nothing, I am innocent ! ' 

" At the third, ' I suffer ! My God ! ' 

" At the fourth, ' Enough, enough ! Jesus ! Mary ! ' 

" Placed on the large trestle. 

u At the fifth, said nothing. 

" At the sixth, idem. 

" At the seventh, 'I can confess nothing.' 

" At the eighth, ' Ah, I am dead.' 

" Was then placed in bed." 

It would be interesting to know the future progress of the 
case of A. The probability is that, after he got beyond the 
tender ministrations and persuasive arguments of M. Leuret, 
he reasserted his delusions with as much vigor as ever. 
At any rate, it is quite certain that M. Leuret' s views and 
practices of "moral" treatment never made any headway, 
even in France, where they originated. In fact, intimidation 
of any kind, while it may make lunatics, as it would many 
other persons, renounce the expression of beliefs they have 
held, I do not see how it can change the belief itself. So long 
as the morbid condition of the brain remains, so long will the 
morbid condition of the mind continue. Whatever good ef- 
fects resulted from it were doubtless mainly due to the re- 
vulsive effect of the cold water. During the early stages of 
those forms of insanity in which there are delusions, any at- 
tempt, either by mental or physical means, to control them 
generally results in their being still more tenaciously held. 
Many lunatics have gone to the scaffold, the stake, and the 
whipping-post, and have endured all kinds of torture, rather 
than renounce their opinions, as have also many sane per- 
sons. But, while intimidation can be of no permanent service, 
it should not for a moment be supposed that the lunatic 
should be humored in his false conceptions, or that any coun- 
tenance should be given to the delusions of which he may 
speak. 1 Whether his ideas should be combated by arguments 
addressed to his reason, is a somewhat different matter. It 
has been said that it is useless to attempt to convince a lu- 

1 The only possible exception to this rule is in certain cases of hypochon- 
driacal mania, where the delusion is clearly traceable to some circumstance of 
actual occurrence. In such cases it may be advisable to accept for the moment 
the statements of the patient in regard to his sensations and beliefs, in order to 
cure him by some such procedure as that, the details of which are given on page 
433, 



740 DESCRIPTION AND TREATMENT OF INSANITY. 

natic that his erroneous notions are not true. Perhaps this 
is correct when serious structural lesions exist in the brain. 
The false intellectual conception is then a fixed result of the 
altered brain-tissue, and is just as direct a consequence of 
cerebral action as is a natural thought from a healthy brain. 
Still, we know that in health it is sometimes possible by argu- 
ment to counteract the most firmly rooted ideas ; it is, perhaps, 
yet easier to do this by the aid of certain of the pleasurable 
emotions. And there appears to be no reason why the like 
result may not occasionally be produced by arguments ad- 
dressed to a person with an insane mind, and by bringing into 
action those feelings which spring from kindness. We know, 
in fact, that this end is at times accomplished, and that, by 
never for one instant admitting the truth of an insane delu- 
sion, and at suitable times — not obtrusively, but when occa- 
sion offers — urging such arguments against it as would be 
convincing to persons of sound minds, the lunatic comes at 
last to see the falsity of his ideas, and to laugh at them him- 
self. Little by little he loses faith in his perverted reason, 
and though he may take up another delusion, the last is held 
with much less tenacity than the first. 

Amusements, especially those which can be taken in the 
open air, are almost always of service, and a proper system of 
rewards and punishments for good and bad conduct is under- 
stood by all but the most furious maniacs. Kindness and 
forbearance, supported by firmness, will not altogether fail in 
their influence with even the most confirmed and degraded 
lunatics. Probably the most difficult class of patients to 
manage by moral means is that of the reasoning maniacs, and 
next to them those cases of hysterical mania which exhibit 
marked perversities of character and disposition. But even 
with such people the principles of justice and fair dealing 
will not be lost, and eventually an impression will probably 
be made on subjects incapable of being touched by other 
measures. 

Hygienic Treatment. — The most important point to be 
considered in this connection is occupation. This is naturally 
of two kinds, mental and physical. 

The system of setting mental taslcs to lunatics is one 
which is rarely if ever followed in or out of asylums, and yet 
it is one from which the best results are likely to flow. , Leuret ' 

x *'Du traitement moral <le la folie," Paris, 1840, p. 172; 



THE TREATMENT OF INSANITY. 741 

states that, a school being established at the Bicetre 'for the 
teaching of reading, writing, arithmetic, and orthography to the 
inmates, he profited by the occasion to make use of its facili- 
ties for some of the lunatics under his charge with manifest 
advantage. If school-teachers — and there are many inmates 
of asylums who could perform the duty with efficiency — were 
appointed to every asylum, and the patients whose cases ad- 
mitted of it were divided into groups according to their form of 
insanity and intelligence, and systematically caused to exer- 
cise their minds in a direction different from that in which 
they would otherwise flow, the best results would, I am satis- 
fied, be obtained. Reading, language, natural history, and 
other classes might thus be established, vocal and instrumen- 
tal music might be properly included in the curriculum, and 
not only would the lunatic's life be rendered happier, but a 
powerful curative influence would be brought to bear upon 
him. I have already given a striking instance (page 438) of 
the diversion of a gentleman's impulses from stealing to the 
collection of bottle-corks. Leuret made some of his patients 
tax the memory with verse, which he required them to learn 
by heart — and with manifest benefit to their state of mental 
health. I have on several occasions succeeded by such means 
in directing the thoughts in such a manner as to abort what 
there was every reason to believe was an attack of some form 
of insanity. In one instance, a young lady had incipient de- 
lusions of persecution, from which she was entirely freed by 
means, of which the systematic exercise of her power of atten- 
tion and of memory were among the chief. She learned to re- 
peat from memory the whole of Campbell's " Pleasures of 
Hope," besides many other shorter pieces, and took such a 
degree of interest in her new work that she had little time left 
for her delusions. 

Physical occupation should alternate with that provided 
for the mind. Where there is a farm or garden, work can be 
found for many able-bodied lunatics who otherwise would be 
troublesome people to deal with. Many a time a superfluous 
amount of nervous energy, which otherwise would have been 
expended in violent or disorderly conduct, has been gradually 
expended by manual labor. For women or the more feeble 
male patients, basket-making and various kinds of ornamental 
and fancy work might readily be provided. 

The good effects of these means cannot be overestimated. 



742 DESCRIPTION AND TREATMENT OF INSANITY. 

To a great extent they have been neglected in American asy- 
lums — though there are several worthy exceptions — to the 
vast detriment of the patients who day after day pass the 
time either a prey to their morbid thoughts or in making 
themselves noisy and troublesome occupants of the wards. 

Baths are valuable hygienic adjuncts, besides being indis- 
pensable for purposes of cleanliness. In facilities for using 
water, American asylums are generally far in advance of those 
of any other part of the world, and yet it is quite true that 
they rarely make systematic use of the great advantages in 
this respect which they possess. 

Baths should be either warm or cold, according to the in- 
dication to be fulfilled. In cases of acute mania and melan- 
cholia the warm bath at night has a decidedly quieting effect, 
and will often procure sleep which would not be otherwise 
obtained but by the use of drugs. It is useful, also, in many 
cases of hysterical mania and of puerperal insanity. In cho- 
reic insanity I have witnessed the most beneficial effects from 
warm baths at night, the temperature being rather high — from 
100° to 105° Fahr. — and continued for not longer than five or 
six minutes. They should be given just at bed- time. Indeed, 
there is scarcely a form of insanity in which a warm bath at 
bed-time is not of service. 

Cold baths require to be used with more caution, and are 
not of such general applicability as those of warm water. In 
some cases of acute mania they are useful, but the duration 
should not exceed two or three minutes, and they should only 
be employed with strong and able-bodied patients. 

Employed in the form of the douche or shower bath, cold 
water has had a high reputation as a therapeutic agent in the 
treatment of insanity, and certainly it has an almost immedi- 
ately quieting effect upon many cases in which there is great 
mental and motorial excitement. Great care, however, should 
be exercised in its use, as, if continued for too long a time, 
alarming prostration may be the result. I have seen strong, 
healthy men brought to such a state of debility as to be un- 
able to speak or stand from the use of the cold shower bath 
on the head for three minutes, and I have known of death 
from its use for seven minutes. I do not think it should ever 
be continued in the cases of the insane for a longer period 
than two minutes, and one minute in the vast majority of cir- 
cumstances would be better. 



THE TREATMENT OF INSANITY. 743 

Brierre de Boismont, 1 basing his memoir on seventy-two 
cases of insanity, recommended, many years ago, the treatment 
of insanity by means of prolonged warm baths for the body 
and irrigation of cold water to the head. Of these cases, 
thirty-five were of acute mania, ten of maniacal exaltation, 
eleven of delirium tremens, ten of monomania, and six of 
chronic intermittent mania. Of the thirty-five cases of mania, 
thirty-three were cured ; of the eleven cases of delirium tre- 
mens, all were cured ; of the ten cases of maniacal exaltation, 
six were cured ; and of the ten cases of monomania, all were 
cured. The six cases of chronic intermittent mania resisted 
treatment. 

The duration of the treatment was from one to fifteen 
days. 

The average number of baths used for each patient was 
six. 

The treatment consisted of baths of the temperature of 28° 
to 30° Cent. (82° to 86° Fahr.), which were allowed to cool 
slowly, and in which the patients were kept for ten, twelve, 
or fifteen hours, while a slender stream of cold water of the 
temperature of 15° Cent. (57° Fahr.) fell on the head from a 
height of from three to four feet. He arrives at the conclu- 
sion, which seems warranted to some extent by the facts, that 
all kinds of insanity, and especially acute mania, can be cured 
by this means in from one to two weeks. 

Several years subsequently Pinel a (nephew) reported that, 
of one hundred and fifty-seven cases treated after this method, 
one hundred and twenty -five were cured, and that, of the 
thirty-two that were not cured, twenty -five were improved. 

Other alienists, among them Baillarger and Guislain, 
speak highly of this form of baths in insanity, and there is 
no doubt of its efficacy in many cases. It requires care and 
close watching, in order to avoid extreme weakness or syn- 
cope, and should never, therefore, be left entirely to an at- 
tendant. 

Nothing among general hygienic measures conduces more 

1 "De l'emploi des bains prolonges et des irrigations continues dans le traite- 
ment des formes aignes de la folie et en particulier de la manie," Bulletin de 
Vacademie royale de medecine, 1846, t. xi, p. 1458; also, Memoires de Vacademie 
royale de medecine, 1848, t. xiii, p. 598. 

2 " Traitement de l'alienation mentale aigue paries bains prolonges," Bull, 
de Vacademie de medecine, 1852, t. xviii, p. 179. 



7U DESCRIPTION AND TREATMENT OF INSANITY. 

to the well-being of insane patients of the melancholic types 
than a full supply of fresh air and sunlight — and even acute 
maniacs are benefited by exposure to both these agencies for 
a portion of the day outside of the building in which they 
may reside. With the latter, however, too strong a light, 
long continued, is calculated to increase excitement. The 
morning sun and air are better than those of the evening. It 
is scarcely necessary to say that the sensation roused a few 
years ago relative to the beneficial influence of blue light was 
altogether unwarranted by theory or facts. 

Medicinal Treatment. — Looking upon insanity of all kinds 
as being the direct consequence of morbid conditions of the 
brain of more or less severity and permanency, it is, of course, 
a logical inference that the brain is the chief organ to which 
our remedies are to be addressed. At the same time there 
may be conditions of other parts of the body which have in- 
duced the brain disorder, and there may be various second- 
ary states which require to be treated in order that the pa- 
tient may be the sooner restored to health. 

In the consideration of this division of the treatment of 
insanity, it appears to be the better plan to continue the sys- 
tem adopted in the other divisions, and to take up in turn 
the various remedies to which it appears desirable to direct 
attention ; to pursue the other plan of taking up the forms of 
insanity in their turn, and describing the modes of treatment 
proper for each, would lead to endless and tiresome repe- 
titions. 

The Bromides. — For the purposes of the present inquiry, 
the bromides of potassium, sodium, ammonium calcium, and 
lithium may be considered as of similar, and, in fact, almost 
equal power and efficacy. For general use, I prefer the bro- 
mide of sodium, for the reasons that its taste is more pleasant 
than that of the others, that it appears to be more readily 
taken into the system, and that it acts more promptly. But 
it is to be understood that all I shall have to say in regard to 
the therapeutical effects of the bromide of sodium applies 
equally to any of the other bromides mentioned. 

In another work ' I have detailed the observations and ex- 
periments which brought me to the conclusion that the bro- 
mides act upon the vaso-motor system in such a way as to 
lessen the amount of intracranial blood by diminishing the 
1 v ' On Sleep and Insomnia," New YorTc Medical Journal, June, 1865, p. 203. 



THE TKEATMENT OF INSANITY. 745 

calibre of the blood-vessels. For many years I have acted 
upon the fact thus established, and have used the bromides 
extensively in the treatment of those forms of mental de- 
rangement dne to a hypersemic or congested condition of the 
brain. In those cases in which there are the somatic phe- 
nomena of cerebral hyperemia, such as pain, a feeling of ful- 
ness, distention, or tightness in or around the head, vertigo, 
and, above all, wakefulness, the bromides can be relied upon 
with almost absolute confidence to restore the healthy state, if 
recourse is had to them at a sufficiently early date. Indeed, 
there are few cases of perceptional insanity, morbid im- 
pulses, or morbid fears, in the early part of their course, 
which resist their systematic and intelligent employment. 
The uncomfortable feelings in the head disappear, the pa- 
tient once more sleeps well, and the mind gradually gets rid 
of its aberrations and resumes its normal condition. 

In such cases the medicine does not require to be given 
in large doses. Fifteen grains of the bromide of sodium three 
times a day, continued for at least a month, will generally be 
sufficient to produce sleep in the course of two or three days. 
If not, then larger doses may be administered till this result 
ensues, when they may be reduced. 

In the management of intellectual monomania with exal- 
tation, or intellectual monomania with depression, somewhat 
larger doses are required, twenty grains of the bromide of 
sodium three times a day being , about an average dose. It is 
also necessary to give it for a longer continuous period, until, 
in fact, decided evidences of bromism are induced. I have 
persevered with it in cases of either of these forms for six 
months without intermission, the condition of the patient 
gradually improving through the whole period, and an ulti- 
mate cure being effected. 

In emotional monomania other than those varieties em- 
braced under the designation of morbid fears, its influence in 
eradicating the mental disease is not so well marked, though 
I have succeeded with it in several striking instances of this 
form of insanity. 

In simple melancholia it is sometimes beneficial, espe- 
cially in those cases in which there are the somatic evidences 
of cerebral congestion, and which have not been of very long 
duration. Relapses, however, are apt to ensue, and in such 
cases it can rarely be got to act favorably again. 



716 DESCRIPTION AND TREATMENT OF INSANITY. 

In melancliolia with delirium and melancholia with stu- 
por it has no very decided influence. 

I have succeeded in several recent cases of hypochondri- 
acal mania in entirely arresting the course of the disease 
and restoring the patient to his normal condition. In one 
case which had lasted over a year, and which was a few 
weeks since before my class at the New York Post-Graduate 
Medical School, the delusions entirely disappeared in about 
two months under the use of the bromide of sodium and alo- 
etic purges. 

Few cases of uncomplicated hysterical mania resist the 
continued use of the bromides in sufficiently large doses. If 
there is much mental and physical excitement, I usually give 
a hundred grains at a dose, and repeat it in twelve hours, or 
even less, if occasion seems to require. Then the medicine is 
continued in doses of from fifteen to twenty grains three 
times a day for as long as may seem necessary. Relapses are 
not uncommon, however, and then, unless a considerable in- 
terval has elapsed, the bromide does not act so well as in the 
first instance. They are also useful in some cases of aboulo- 
mania, in which there are marked symptoms of cerebral hy- 
peremia. In the fourth case of my own, described under 
that head, the bromide of sodium always controlled the 
trouble so long as the patient took it. 

In acute mania, as well as in periodical and circular in- 
sanity, large doses of the bromides are important adjuncts in 
the treatment, and they may be continued in addition to other 
measures of more rapid action. They certainly exercise a 
beneficial effect in allaying excitement and in facilitating a 
favorable result. 

In /catatonia they are even still more advantageous. Here, 
also, large doses — from fifty to a hundred grains — should be 
given at first — for two or three days — and then when the force 
of the disease is broken, doses of fifteen or twenty grains 
three times a day will be sufficient. 

In the early stages of general paralysis, and during any 
paroxysm of excitement or convulsion occurring in the course 
of the disease, the bromides are useful in quieting the patient 
and giving sleep. 

In epileptic insanity they are indispensable, but they may 
have to be given for several years, or even during the lifetime 
of the patient. Indeed, many patients have paroxysms of 



THE TKEATMENT OF INSANITY. 747 

the disease if the administration be stopped for only a few 
days. They should be given in large doses at first, and then 
subsequently in smaller ones, in cases in which the accessions 
are frequent and very severe. In milder cases the doses need 
not exceed fifteen grains three times a day for the first six 
months, with an increase of five grains every six months for 
two or three years. 

In a patient recently under my charge, and in whom there 
were monthly attacks of epileptic insanity corresponding with 
the menstrual period, the attacks could always be prevented 
by a dose of a hundred grains of bromide of sodium, taken 
with the appearance of the menstrual discharge. 

la. puerperal insanity the bromides are almost invariably 
useful, especially in the beginning of the attack. The doses 
should at first be about thirty grains three times a day, which, 
as the patient passes under the influence of the medicine, may 
be reduced to fifteen grains. 

In choreic insanity they are occasionally useful, though 
often more rapidly acting remedies are required. A large 
dose, taken just before bedtime, will, however, generally prove 
serviceable in stopping the hallucinations of sight to which 
patients with this form of insanity are subject. 

It must not be forgotten, however, as previously stated, 
that the bromides sometimes themselves cause mental de- 
rangement. An analogous fact has been noted by Dr. H. M. 
Bannister, 1 who found that in certain insane epileptics — not 
cases of epileptic insanity — an increase of excitement was 
caused by the bromides. He is, however, inclined to regard 
this result as rather due to the suppression of the convulsive 
seizures than to any direct effect of the medicine. 

Opium and its Preparations. — The preferable form in 
which to administer an opiate in cases of insanity is un- 
doubtedly some one of the salts of morphia. In this coun- 
try the sulphate is the one generally in use. 

Morphia, systematically administered, is of undoubted effi- 
cacy in many forms of insanity as a curative agent, in addi- 
tion to the immense benefit to be derived from its employ- 
ment in cases in which an immediate calming effect is desired. 

Morphia is especially beneficial in the treatment of those 
forms of insanity which are characterized by mental depres- 

1 " Note on a Peculiar Effect of the Bromides on certain Insane Epileptics," 
The Journal of Nervous and Mental Disease, July, 1881, p. 560. 



7±8 DESCRIPTION AND TREATMENT OF INSANITY. 

ston. Although it had been previously used with success in 
other cases, Clerici ' appears to have been the first to use it 
with a clear conception of its method of action in a case of 
melancholia, and shortly afterward Marce 2 employed opium 
in a similar case with a successful result. 

If melancholia is, as Meynert asserts, the result of ex- 
hausted brain action conjoined with a deficient supply of ar- 
terial blood, the indications would, of course, be to secure 
rest for the over-excited organ, and to increase the flow of 
blood to its arteries. 

In a valuable memoir, Dr. Courtenay, 8 of the Derby 
County Lunatic Asylum, England, insists upon the use of 
opium as a remedy calculated to fulfil the objects in view, 
and he relates the details of a number of cases in which 
the most favorable results followed. Indeed, he regards 
opium in small doses as the most valuable of all medicines in 
the treatment of the condition in question. He appears, how- 
ever, to be unaware of some experiments of my own (already 
described in this work, p. 156), performed several years ago, 
which tend to enforce very decidedly the correctness of the 
conclusions which he has reached by independent observa- 
tions. The inference from these experiments, as well as from 
those of Dr. Courtenay, is that opium should be administered 
with discrimination, and that, when the object is to stimulate 
an exhausted and anaemic brain, the doses should be small. 
In my own practice in the class of cases under consideration, 
I have always derived very great benefit from doses rarely 
exceeding half a grain, repeated three or four times a day, 
and continued systematically for several weeks. Or from the 
eighth to the sixth of a grain of the sulphate of morphia may 
be given as often by the mouth, or twice daily as a hypodermic 
injection, if the patient will not take the medicine other- 
wise. 

Yoisin 4 is also an advocate for the continued use of mor- 
phia in all forms of insanity in which there is reason to sus- 
pect the existence of cerebral anaemia. 

In larger doses I have found, in accordance with the ex- 

1 Gazzetta medica de Lombardia, Novembre, 1856. 

2 Annates medico-psychologiques, 1859. 

9 " The Use of Opium in the Treatment of Melancholia," West Riding Lu- 
natic Asylum Medical Reports, vol. ii, 1872, p. 254. 

4 " Lecons cliniques sur les maladies mentales," Paris, 1883, p. 687. 



THE TREATMENT OF INSANITY. 749 

periments referred to, that morphia is an efficient adjnnct to 
the bromides in the treatment of all the forms of mental de- 
rangement in which they are nseful. As a small dose pro- 
duces cerebral hyperemia, a moderate dose causes cerebral 
ansemia. It should, therefore, when used, in hypersemic 
forms of insanity, in conjunction with the bromides, be given 
in doses of a quarter of a grain once or twice a day, or a grain 
of opium may be administered in like manner. I have fre- 
quently obtained the most happy results by the employment 
of the drugs in their combined form. 

In cases of acute mania, or of melancholia with delirium, 
or of any other variety in which there is a state of high men- 
tal and physical excitement, hypodermic injections of from 
half a grain to a grain of sulphate of morphia will often quiet 
the patient and induce a sound sleep of several hours' dura- 
tion. Such a quantity as my experiments show, given to a 
healthy man, would cause stupor, and perhaps death. 

Chloral Hydrate. — As a means of securing sleep, chloral is 
sometimes of service, though I very seldom employ it, owing 
to the uncertainty of its action so far as the life of the patient 
is concerned. It is used extensively in lunatic asylums, how- 
ever, not as a curative agent, but solely as a hypnotic. I have, 
however, known a person to take doses with impunity which 
afterward resulted in her death. 1 It is not so much a hyp- 
notic as it is a soporific. 

Hyosciamus, or rather hyosciamine, is a valuable adjunct 
in the treatment of conditions of mental excitement, espe- 
cially when conjoined with great motorial activity. I have 
given as much as the twentieth of a grain of the crystallized 
hyosciamine by hypodermic injection with excellent effect in 
a case of acute mania, and a like dose in a case of general 
paralysis in which there was an exacerbation of mania. In 
an instance of melancholia with stupor four drops of a solu- 
tion of a grain of Merck's crystallized hyosciamine to one 
ounce of water, equal to about the one hundred and twentieth 
of a grain, were given three times a day with good results. 
The quantity was gradually increased up to fifteen drops — 
nearly the thirtieth of a grain — three times a day, some six 
weeks being taken to reach this dose, the patient gradually 

1 " Fatal Cerebral Congestion following the Administration of Hydrate of 
Chloral," by George G-. Needham, M. D. The Journal of Psychological Medi- 
cine, January, 1871, p. 93. 



750 DESCRIPTION AND TREATMENT OF INSANITY. 

improving and ultimately going on to recovery, even after the 
administration was stopped. 

Digitalis. — I have used digitalin in simple melancholia 
and in melancholia with stupor. In the latter affection its 
action is sometimes particularly good. In the case of a young 
lady from New London, suffering from this form of mental 
derangement, the doses were carried up to the twentieth of a 
grain three times a day, beginning with the sixtieth. In this 
case the bromides had been given, before I saw the patient, 
with a decidedly deleterious effect. The digitalin acted well. 
The force of the heart was increased, her general circulation 
became more active, and complete recovery was the result. 
In another similar case, however, it produced no effect upon 
the mental condition, though given in doses of the tenth of a 
grain. 

Conium. — The fluid extract of the seeds is the most eligi- 
ble preparation of this drug to employ, and, as Dr. Seguin 
has shown, it may be given in much larger doses than are or- 
dinarily thought admissible. There is, however, in my opin- 
ion, no form of insanity in which it is particularly indicated, 
though it may be useful in those cases in which there is men- 
tal and motorial excitement — choreic insanity, for instance. 

Ergot, especially in combination with the bromides, is an 
exceedingly useful remedy in the hypersemic forms of in- 
sanity. I usually give the fluid extract as the solvent instead 
of water for the bromide of sodium. It is indicated in all 
those varieties in which the bromides are useful. 

Amyl Nitrite. — Inhalations of the nitrite of amyl are often 
of especial value in the treatment of the paroxysms of hys- 
terical mania of the variety known as hystero- epilepsy. Ten 
drops may be poured on a handkerchief, and held over the 
nose and mouth. Similar treatment is frequently efficacious 
in the accessions of epileptic mania. In either case the ad- 
ministration may be made immediately before an expected 
seizure or during its action. 

It is also useful in cases of melancholia generally. In the 
instance of a lady suffering from simple melancholia, who had 
several times attempted to commit suicide, and who had been 
for six months in a lunatic asylum, no other medicine was 
given, and the result was a complete recovery in about five 
weeks. In this instance ten drops of the remedy were ad- 
ministered by inhalation six times a day. 



THE TREATMENT OF INSANITY. 751 

I have used the drug internally in doses of a drop or more 
up to ten drops, with the idea of preventing the paroxsyms 
of both these affections, but without any notable result. 

Nitro-glycerine, or glonoine, as an internal remedy for 
certain forms of insanity, is of unquestionable value. A solu- 
tion of one per cent in alcohol is a safe preparation to employ, 
and in the beginning the dose should not exceed a drop, 
which, however, may be taken if necessary every hour or 
two. I have used it in this way in the treatment of simple 
melancholia, in melancholia with stupor, in hysterical mania, 
in primary dementia, and in epileptic insanity, and have 
found it a valuable remedy. It is especially indicated in 
those forms of mental derangement in which cerebral anaemia 
is the chief intracranial morbid condition, such as the groups 
of melancholias and dementias. 

I have also used it with entirely satisfactory results in 
three of the cases of aboulomania referred to when the symp- 
tomatology of the disease was under consideration. Whether 
this affection be due to a state of passive congestion or of 
ansemia of a portion of the brain, nitro-glycerine would appear 
to be indicated, and the results have been, in my experience, 
in accordance with the views I have expressed relative to its 
pathology. I gave a drop every hour for sixteen hours a day 
in the three cases first described, and continued this treat- 
ment for twenty days. After the second day in one case — 
the second — and the third day in the others, the power of the 
will began to augment, and gradually reached its normal 
degree of force, so that by the twentieth day no difficulty was 
experienced in causing it to act. The medicine was continued 
in the doses of two drops three times a day for a month longer, 
and then its administration was entirely stopped. In none of 
the cases has there been, so far as I know, any recurrence of 
the trouble. In the fourth case, which was one of long stand- 
ing, the condition was aggravated by the nitro-glycerine. 

Mtro-glycerine can be also given in the form of pills, 1 each 
one of which contains the one hundredth of a drop of the sub- 
stance, but I prefer the solution, as acting more rapidly. 

Sulphuric ether is of very limited application in the treat- 
ment of insanity. I have used it only in a few cases of hys- 
terical mania, epileptic insanity, and choreic insanity. Its 

1 As prepared by Metcalf, of Boston, whose solution I have also found emi- 
nently satisfactory in its action. 



752 DESCRIPTION AND TREATMENT OF INSANITY. 

effects are temporary only so far as the first two named are 
concerned, but in choreic insanity it has exercised a tranquil- 
lizing influence which did not altogether cease with the re- 
turn of the patient to consciousness. 

Bromide of Ethyl, — This substance was recommended two 
years ago by MM. Bourneville and d'Olier, 1 who used it with 
success in several cases of hysterical mania, hystero-epilepsy, 
and epilepsy. Recently Roux 2 has employed it in two cases 
of acute mania, of which one was cured. 

My personal experience with this agent in the treatment 
of insanity is limited to a single case of intellectual mono- 
mania with depression. In this case there were hallucina- 
tions of voices uttering abuse and threats of violence, with 
delusions of persecution. After each inhalation the patient 
was decidedly better, both the hallucinations and delusions 
being of less intensity, and occasionally disappearing alto- 
gether, but they soon returned ; and, as after two weeks' 
treatment there was no improvement, the use was discon- 
tinued. 

I gave it twice daily in doses of from a drachm to a drachm 
and a half dropped on a handkerchief two or three times, 
and held to the mouth. I continued the anaesthetic condi- 
tion for fifteen or twenty minutes each time. No ill effects 
attended the administration. In view of the experience gained 
by Roux, it would appear that the remedy is worthy of fur- 
ther trial, and especially in cases of acute mania. 

Iodide of Potassium. — The iodide of potassium has been 
used with benefit in some cases of general paralysis, and I 
have myself employed it with advantage in this affection. 
Apparently, under its influence the delusions have ceased to 
exist, many of the somatic symptoms have disappeared, and 
the patient has resumed his ordinary business. Eventually, 
however, in all but two cases they have reappeared. In these 
two instances, the intermissions have been thus far respec- 
tively eighteen months and six months, and both patients are 
free from all signs of mental aberration, except, perhaps, a 
slight degree of emotional impressionability, and from all phys- 
ical symptoms except inequality of the pupils. In both cases 
the disease was of syphilitic origin, or, at least, the patients 

1 " Recherches sur- Paction physiologique et therapeutique de homme d'ethyle 
dans Fepilepsie et de Thysterie, 1 ' Gazette medicate de Paris, 26 mars, 1881, p. 173. 

2 These de Paris, 1882. 



THE TREATMENT OF INSANITY. 753 

had had primary disease. The doses in both cases were car- 
ried up to one hundred and twenty grains three times a day, 
and at intervals the medicine is still taken. Of course, these 
results may be mere coincidences, as remissions lasting as 
long as these are occasionally met with. 

The iodide of potassium is of great service in all forms of 
insanity which are of syphilitic origin. It should be given 
in gradually increasing doses, up to one, two, or even three or 
four hundred grains at a dose if the diagnosis as to the cause 
is clear, and amendment does not result from smaller quan- 
tities. 

Mercury is useful as an adjunct to the iodide of potassium. 
I usually give, in the cases in which the latter drug is indi- 
cated, from the thirtieth to the sixteenth of a grain of the bi- 
chloride with each dose of the potassium salt. 

Mercury is sometimes useful as a purgative, but the occa- 
sions for its employment for this object are not many. 

Strychnia and phosphorus are of advantage as tonics in 
all cases in which the vital powers are low, and which are 
such as may be supposed to result from an ansemic condition 
of the brain. These are included in the groups of melancho- 
lias and dementias. The former substance can almost always 
be relied upon in doses of from the sixtieth to the thirtieth 
of a grain three times a day, to increase the activity of the 
cerebral circulation. 

Quinine and iron have a like applicability. In melan- 
cholia with stupor quinine in conjunction with strychnia is 
often of striking efficacy. 

Arsenic is a very valuable remedy in all forms of the hy- 
persemic or congestive type. It is certainly a powerful agent 
in diminishing the amount of intracranial blood, as Lisle 1 
pointed out several years ago. I generally give it in the form 
of the pills of arsenious acid which are now found ready-made 
at the pharmacists. The dose at first may be the twenty-fifth 
of a grain three times a day after eating, and the number of 
pills should be gradually increased for several weeks up to 
four or five at a dose — that is, to about half a grain daily. It 
is indicated in all those forms in which the bromides are use- 
ful, and may be given with advantage in conjunction with 
them. Fowler's solution may be administered instead of the 

1 "Du traitement de la congestion cerebrale et de la folie avec congestion et 
hallucinations par l'acide arsenieux," Paris, 1871. 
48 



751 DESCRIPTION AND TREATMENT OF INSANITY. 

arsenious acid in its solid form in corresponding quantities, 
though it has appeared to me that the latter preparation is 
preferable. 

Besides its own specific effect upon the brain, arsenic is an 
excellent tonic, and tends to prevent the excessive debility 
which sometimes accompanies the use of the bromides in large 
doses. 

There are other medicines which are also of great service in 
the treatment of insanity, to obviate certain pre-existing, ac- 
companying, or secondary conditions. Thus, emmenagogues 
are indispensable when there is a functional arrest of the men- 
strual flow ; diuretics, when the kidneys are inactive ; purga- 
tives, when the bowels are constipated ; and so on with other 
classes of remedial agents. The latter are very generally re- 
quired at some time or other in nearly every case of mental 
derangement. 

Schroeder van der Kolk ' has pointed out the efficacy of 
aloetic purges in certain cases of mental derangement with 
depression, accompanied with accumulations in the colon. I 
have frequently had occasion to be gratified with the success 
obtained by following the plan of treatment in question. I 
often give a grain of the watery extract of aloes in pill three 
times a day for a month, or even more if necessary, and 
again one pill at bedtime only, consisting of two grains of 
the watery extract of aloes, three of inspissated ox-gall, and 
from a quarter to half a grain of podophyllum Under this 
plan of treatment I have repeatedly seen the most intense 
melancholia disappear in a few days. The treatment is also 
of service in all forms of insanity except the dementias 
and certain of the constitutional types, unless specially con- 
traindicated. 

Electricity. — In the chapter on insanity in the earlier edi- 
tions of my work on " Diseases of the Mind and Nervous 
System," I stated that " electricity had not in my hands been 
productive of any marked benefit, though I have used it in 
all its various forms and methods." Since those lines were 
written, the great improvements which have been made in the 
construction of statical or Franklinic electrical machines have 
enabled us to employ statical or Franklinic electricity to 

1 "Die Pathologie und Therapie des Geisteskranken auf anatomisch-physiolo- 
gischer Grundlage," Braunsweig, 1863, p. 185 et seq. ; also, translatioD by Dr. 
James T. Rudall, London, 1870, p. 134. 



THE TREATMENT OF INSANITY. 755 

much better effect than was then possible. I now very gener- 
ally employ it as a counter-irritant, capable of making a very 
rapid and decided impression on the system. In cases of 
mental derangement coming under the class of emotional in- 
sanities, and in primary and secondary dementia, it is of de- 
cided benefit. I place the patients on the insulated stool and 
draw long sparks from the whole length of the spine. They 
very generally express themselves as feeling better, and they 
are perfectly willing to have the operation repeated. Whether 
or not the action is anything more than that of a counter-irri- 
tant I do not pretend to know. The seance may be repeated 
daily, or every alternate day, for as long as benefit appears to 
be derived. No single application should last longer than ten 
minutes. 

Dr. Clifford Allbutt ' has called attention to the good re- 
sults derivable from the use of the continuous or galvanic 
current in certain forms of insanity. In cases of acute pri- 
mary dementia decided improvement took place ; in mania 
and atonic melancholia — melancholia with stupor — the benefit 
was less decided ; in chronic dementia and in some cases of 
melancholia, no effect was produced ; while in hypochondri- 
acal melancholia and, perhaps, in brain wasting, the result was 
unfavorable. 

General bloodletting, once so much in vogue, can scarcely 
ever be required at the present day. There may be cases of 
acute mania in which it might be useful, and perhaps also 
certain instances of epileptic insanity, but certainly no others. 
On the other hand, local bloodletting by cups or leeches 
is often a useful measure, especially in those cases in which 
there are pain and heat in the head accompanied with insom- 
nia and excitement. A half dozen or so of cups to the nape 
of the neck, or as many leeches to the temples, are often of 
marked and immediate advantage. A couple of leeches to 
the inside of the nostrils are remarkably efficacious in reliev- 
ing cerebral hyperemia and mitigating the violence of the 
physical and mental symptoms resulting from it. 

In milder cases, dry cups may be applied to the nape of 
the neck and upper part of the spine every day with good 
results. 

As to counter-irritants, such as blisters, croton oil, tar- 

1 " The Electric Treatment of the Insane," West Riding Lnnatic Asylum 
Medical Reports, vol. ii, 1872, p. 203. 



756 DESCRIPTION AND TREATMENT OF INSANITY. 

tarized antimony, and the actual cautery, cases every now 
and then appear in which they seem to be of service. I have, 
however, several times aggravated the mental and physical 
symptoms of insanity by their nse. I suppose the most gen- 
erally advantageous agent of the kind is the actual cautery 
very lightly applied to the nucha, but then the action in such 
a case can scarcely be called counter-irritant. 

In a few cases of chronic intellectual mania I have de- 
rived slight benefit from the use of croton oil to the scalp, but 
it is scarcely worth while to go through so much to get so 
little. 

The application of cold to the head or nape of the neck is 
useful in all cases of insanity belonging to the hyperaemic 
type, unless there is some special reason why it should not be 
employed. In mild cases it is sufficient to apply a lump of 
ice to the nape of the neck for two or three minutes just 
before going to bed. It generally aids effectually in produc- 
ing sleep. In more severe cases the ice may be applied in a 
special ice-bag to the upper part of the spine and the occiput, 
and in others to the cortex. 

In those cases due to cerebral anaemia embraced in the 
groups of melancholias and dementias, heat immediately ap- 
plied is of great service, not only in quieting agitation when it 
exists, but in rousing the mind to something like its original 
degree of activity. I suppose one reason why good results 
have not more generally been derived from its employment 
is that it has not been used to a sufficiently high degree, and 
another is that it has not been continued long enough. The 
bags used for ice may be also used for hot water, and the ap- 
plication may be made in a manner like that employed for 
ice. Water heated up to 120° or even 130° is not generally of 
too elevated a temperature. 



INDEX 



PAGE 

Abnormal mental condition during men- 
struation 108 

Abnormal tendencies excited by men- 
strual cessation 112 

Aboulomania 524 

causes producing 531 

characteristics of 524 

latent force in 532 

pathological anatomy of 702 

Accidental anomalies, hereditary trans- 
mission of , 76 

Acclimation 53 

Acquired eccentricity 38 

Action of the brain 12 

Action of the emotions 22 

Action of the mind, mental and phys- 
ical conditions influencing the . . 34 

Actions, instinctive 128 

line between rational and in- 
stinctive 129 

Acute mania 535 

clearness of intellect in 542 

the countenance in 545 

digestion in 546 

duration of 552 

emotional system in 544 

frenzy in 550 

hallucinations of 539 

loquacity and incoherence in 550 

menstruation in 546 

muscular activity in 545 

nymphomania in 551 

pathological anatomy of 703 

pregnancy in 546 

prognosis of 674 

pulse and respiration in 546 

satyriasis in 551 



PAGE 

Acute mania, symptoms of 533 

temperature in 546 

wakefulness in 549 

the will in 545 

Acute maniacs, habits of 549 

Agoraphobia 419 

Age 88 

Agents producing sleep 156 

Alienation, mental, during pregnancy. . 115 

Ambitious monomania 332 

Animate and inanimate machines, dif- 
ference between 133 

Anthropophobia 424 

Arrested development, idiocy and cre- 
tinism, psychical states of 290 

Arrest of instinct 131 

Arrest of mental development 293 

Astraphobia 424 

Automatic reaction and instinct, differ- 
ence between 133 

Avarice as a cause of insanity 409 

Average weight of brain 13 

Bed-sores in general paralysis 623 

Bloody tumor of the ear 468 

Bodily peculiarities of reasoning ma- 
niacs 378 

Body, weight of, in the two sexes 102 

Boys, insanity during puberty in 113 

Brain, action of the 12 

average weight of 13 

cortical substance of the 34 

differences between the male and 

female 103 

injury or disease of 12 

lowest weight of human 14 

the seat of the emotions 23 



758 



INDEX. 



PAGE 

Brain, seat of instinct not in the 143 

size of 13 

ways of tiring the 171 

weight of the, in several races ... 120 

Brain during sleep, conditions of the. . 162 

vascular condition of the 161 

Capacity, cranial 102 

Carotid compression in inducing sleep, 

influence of 160 

Case of microcephaly 14 

Cause of dreams, the 233 

Cause of habit 54 

Cause of insanity, civilization as a 653 

chagrin as a 655 

cities as a 654 

civil condition as a 652 

fright as a 656 

love as a 656 

malaria as a 668 

masturbation as a 667 

occupation as a 667 

sunstroke as a 666 

Causes diminishing the power of atten- 
tion 172 

Causes of the development of emotions 22 

Causes of hallucinations 315 

Causes of insanity 652 

diseases of the brain as 666 

fungous growths as 660 

intellectual 656 

medicines as 661 

physical 657 

predisposing 652 

wounds as 663 

Causes of nightmare 257 

Causes of sleep 151 

Causes producing aboulomania 531 

Causes tending to make mental aberra- 
tion more common in men than 

in women 117 

Cerebral circulation during sleep, con- 
dition of the 164 

Cerebral haemorrhage, emotions in rela- 
tion to 24 

Cessation of the menstrual discharge, 

period of the 110 

Chagrin as a cause of insanity 655 

Character of instinct, unerring. ....... 142 

Characteristics of aboulomania 524 

Characteristics of hysterical mania... . 486 
Characteristics, sexual 101 



PAGB 

Children, insanity in 84 

Children, suicide in 92 

Choleric temperament 67 

examples of 67 

Choreic affections acquired through imi- 
tation 55 

Choreic insanity 647 

pathological anatomy of 717 

Chronic alcoholic intoxication, diagno- 
sis of 689 

Chronic intellectual mania 354 

diagnosis of 688 

pathology and morbid anatomy of 697 

prognosis of 673 

Circular insanity (folie circulaire) 560 

diagnosis of 688 

pathological anatomy of 705 

period of depression in 562 

period of excitement in 565 

Cities as a cause of insanity 654 

Civil condition as a cause of insanity. 652 

Civilization as a cause of insanity 653 

Civilization, tendency to disease in- 
creased by 120 

Classification of the' forms of insanity 285 
Classification of mental disease, meth- 
ods to be employed in the 285 

Classifications of insanity, clinical. ... 288 

Claustrophobia 423 

Clearness of intellect in acute mania. . 542 

Clinical classifications of insanity 288 

Cold a cause of sleep 169 

Compound insanities 293, 534, 671 

pathological anatomy of 703 

Condition of the cerebral circulation 

during sleep 164 

Conditions attending the period of de- 
cline 99 

Conditions, mental and physical, influ- 
encing the action of the mind. . 34 
Conditions of the brain during sleep. . 162 
Connection between mind and brain. . . 10 

Consanguineous marriages 85 

effects of 86 

Constitution and temperament, differ- 
ence between , 72 

Constitution, definition of 72 

Constitutional defects, modification of. 74 

Constitutional insanities 293, 630 

prognosis of 672, 674 

Convulsive seizures in general paralysis 628 
Cortical substance of the brain 34 



ItfDEX. 



759 



PAGE 

Countenance in acute mania, the 645 

Countenance in insanity, the 684 

Cranial capacity 102 

Cranial capacity of several races 119 

Curative agent of nervous disorders, 

menstruation a 109 

Curious circumstance connected with 

instinct 140 

Dancing mania, or tarentism 513 

Debility producing sleep 173 

Definition of constitution . 172 

Definition of emotion 22 

Definition of genius 48 

Definition of habit 51 

Definition of idiosyncrasy 44 

Definition of insanity 262 

Definition of mind 9 

Definition of perception 15 

Definition of temperament 61 

Definition of will 27 

Definitions of instinct 125 

Degenerations of temperaments 71 

Degenerations, psychical 289 

Delirium 276 

macromaniacal 485 

melancholia with 460 

Delirium of littleness 484 

Delirium of negation 484 

Delirium of persecution 343 

Delusion 268 

Dementia, primary 588 

secondary 593 

senile 594 

tendencies in primary 591 

Demonomania 503 

Depression, intellectual monomania 

with 340 

Derangement, emotions which are sub- 
ject to 22 

Derangement of the bladder in general 

paralysis 625 

Desire and will, difference between 30 

Desire during sleep 209 

Deux, folie a 514 

Development, arrest of mental 293 

Diagnosis of chronic alcoholic intoxica- 
tion 689 

Diagnosis of chronic intellectual mania. 688 

Diagnosis of circular insanity 688 

Diagnosis of glosso-labio-laryngeal pa- 
ralysis 689 



PAGE 

Diagnosis of hysterical mania 688 

Diagnosis of insanity 681 

Diagnosis of intellectual monomania 

with depression 687 

Diagnosis of intellectual monomania 

with exaltation 687 

Diagnosis of periodical insanity 688 

Diagnosis of primary dementia 688 

Diagnosis of progressive muscular atro- 
phy 689 

Diagnosis of reasoning mania. 688 

Difference between animate and inani- 
mate machines 133 

Difference between constitution and 

temperament 72 

Difference between instinct and auto- 
matic reaction 133 

Difference between instinct and reason. 134 
Difference between male and female 

brain 103 

Difference between stupor and sleep. . 155 

Difference between will and desire 30 

Differences of race 117 

Digestion in acute mania 546 

Digestion leading to sleep 173 

Discrimination between genius and 

insanity 49 

Disease, hereditary transmission of . . . 77 
increased by civilization, tenden- 
cy to 120 

maintained by habit 56 

Diseases causing insanity 666 

Diseases of the brain as causes of in- 
sanity 666 

Disposition to deceive in hysterical ma- 
nia 495 

Dispositions, instinctive 131 

Distinction between the exciting and 

the immediate cause of sleep ... 152 

Disturbing mental factors 37 

Division of the symptoms of hypochon- 
dria 477 

Divisions of insanity 287 

Divisions of mind 15 

Dreams, the cause of 233 

essential morbid 250 

the foundation of 214 

influence of, upon the mind 249 

insanity preceded by frightful 237 

morbid 234 

the physiology of 210 

prodromic 234 



760 



. INDEX. 



PAGE 

Dreams produced by odors 226 

symptomatic 247 

treatment of morbid 258 

Duration of acute mania 559 

Duration of general paralysis 629 

Duration of melancholia with delirium 471 

Eccentricity 38 

acquired 38 

instances of 41 

two distinct forms of 40 

Effects of consanguineous marriages . . 86 

Emotion, definition of 22 

production of 25 

Emotion a cause of insanity 25 

Emotional causes of insanity 654 

Emotional insanities 292, 400, 671 

pathological anatomy of 699 

Emotional monomania 401 

prognosis of 673 

Emotional morbid impulses 432 

prognosis of 673 

Emotional morbid impulse to suicide . . 446 

Emotional system in acute mania 544 

Emotions 21 

action of 22 

causes of development of 22 

habitual indulgence of the 59 

in lower animals 23 

in relation to cerebral haemor- 
rhage 24 

mechanism developing the 26 

seat of 22 

seat of, in the brain 23 

which are subject to derangement 22 

Epidemic insanity 503 

pathological anatomy of 702 

prognosis at.f 674 

Epilepsy, masked 631 

Epileptic insanity 630 

pathological anatomy of 715 

prognosis of 672 

Essential morbid dreams 250 

Examples of choleric temperament 67 

Examples of nervous temperament ... 70 
Examples of sanguine temperament . . 64 
Exciting, the, and immediate cause of 

sleep, difference between 152 

Exciting causes of insanity 654 

Exercise of judgment during sleep 193 

Exercise of volition 28 

Exercise of the will during sleep 202 



PAGE 

Factors, disturbing mental 37 

Faculties of intellect 21 

Falling asleep, hallucinations before . . 230 

Fear of spaces 419 

Female brain, weight of 14 

Folie a deux 514 

Folie communiquee 516 

Forcible alimentation in insanity 728 

Form of skull in different races 120 

Forms of insanity, classification of the. 285 

Foundation of dreams, the 214 

Fractured ribs in lunatics 547 

Frenzy in acute mania 550 

Fright as a cause of insanity 656 

Frightful dreams, insanity preceded 

by 237-244 

Frogs, instinct of generation in 147 

Fungous growths as causes of insanity. 660 

General paralysis 596 

bed-sores in 623 

convulsive seizures in 628 

derangement of the bladder in. . . 625 

duration of 629 

hematoma auris in. 623 

melancholia in 609 

mental symptoms of 599 

morbid anatomy of 710 

nutrition in 623 

physical symptoms of 610 

remissions of the intensity of . . . . 626 

sense of hearing in 622 

sense of taste in 622 

temperature of the body in 623 

Generation in frogs, instinct of 147 

Genius, definition of 48 

mental operations of 48 

Genius and insanity, discrimination be- 
tween 49 

Gestures and movements in insanity. . 684 
Glosso-labio-laryngeal paralysis, diag- 
nosis of 689 

Habit, cause of 54 

definition of 51 

disease maintained by 56 

influence of 53 

instances of 57 

transmitted 56 

Habits, regulation of 59 

Habits of acute maniacs 549 

Habitual indulgence of emotions 59 



INDEX. 



761 



Hematoma auris 468 

Heematoma auris in general paralysis. . 623 

Hallucinations 267, 301 

before falling asleep 230 

causes of 315 

in acute mania 539 

incident to hysterical mania 494 

incident to melancholia with deliri- 
um 461 

of hearing 305 

of sight 308 

of smell 310 

of touch 310 

pathology and morbid anatomy of. 321 

voluntary production of 311 

Hearing, hallucinations of 305 

illusions of 297 

Heat, a cause of sleep 169 

Hebephrenia 556 

pathological anatomy of 704 

prognosis of 672 

Hereditary tendency 75 

Hereditary transmission of accidental 

anomalies 76 

Hereditary transmission of disease. ... 77 
Hereditary transmission of peculiarities 75 
Hereditary transmission of qualities. . . 75 
Home or asylum treatment of insanity. 718 

Homicidal mania 441 

Human life, length of 88 

Hunger 19 

Hydrophobophobia 432 

Hygienic treatment of insanity 740 

Hypochondria, division of the symp- 
toms of 477 

Hypochondriacal mania 475 

pathological anatomy of 701 

Hypochondriacal maniacs, illusions of . 477 

Hysterical mania 485 

characteristics of 486 

diagnosis of 688 

disposition to deceive in 495 

hallucinations incident to 494 

in men 502 

pathological anatomy of 702 

periods of 492 

phases of 490, 491 

prognosis of 673 

spontaneity of 486 

Ideation, perception the starting-point 

of 17 



PAGE 

Idiosyncrasies, variations of 45 

Idiosyncrasy 43 

definition of 44 

instances of 45 

Idiots, instincts of 149 

Illusion 266 

Illusions 294 

Illusions of hearing 297 

Hlusions of hypochondriacal maniacs.. 477 

Illusions of sight 295 

Hlusions of taste and smell 301 

Illusions of touch 298 

Illustration of volitional control 27 

Imagination during sleep, the 190 

Imitation as a cause of morbid impulse. 398 
Imitation, choreic affections acquired 

through 55 

Imposed insanity (folie imposee) 515 

Impossibility to improve instinct 139 

Impulses, emotional morbid 432 

Impulses, intellectual morbid 387 

Impulses, volitional morbid 517 

Inability to exert will-power 31 

Incoherence 273 

Increase, period of 90 

Infallibility of instinct 132 

Infants, necessity for sleep in 177 

Influence of carotid compression in in- 
ducing sleep 160 

Influence of dreams upon the mind . . . 248 

Influence of habit 53 

Influence of maternal mind over off- 
spring before birth 77 

Influence of narcotics upon the will.. . 31 

Influence of the will 27 

Injury or disease of the brain 12 

Insanities, compound 293, 534 

prognosis of 671 

Insanities, constitutional 293, 630 

Insanities, emotional 292, 400 

prognosis of 671 

Insanities, intellectual 292 

prognosis of 670 

Insanities, perceptional 292 

prognosis of 670 

Insanities, volitional 293, 517, 671 

Insanity, avarice as a cause of 409 

caused by intense emotion 25 

causes of 652 

choreic 647 

circular {folie circulaire) 560 

classification of the forms of 285 



762 



INDEX. 



PAGE 

Insanity, clinical classifications of ... . 288 

communicated 516 

definition of 262 

diagnosis of 681 

diseases causing 666 

diseases of the brain as causes of. 666 

divisions of 287 

during the period of maturity 98 

emotional causes of 654 

epidemic 503 

epileptic 630 

exciting causes of 654 

forcible alimentation in 728 

fungous growths as causes of . . . . 660 

gestures and movements in 684 

home or asylum treatment of 718 

hygienic treatment of 740 

imposed (folie imposee) 515 

in boys during puberty 113 

in children 84 

intellectual causes of 656 

in young persons 95 

jealousy as a cause of 410 

malaria as a cause of 668 

masturbation as a cause of 667 

mechanical treatment of 724 

medicinal treatment of 744 

medicines as causes of 661 

moral treatment of 729 

occupation as a cause of 667 

of the mother, sex of child a de- 
termining cause of 116 

pathology and morbid anatomy of. 691 

pellagrous 645 

period during pregnancy of 115 

periodical 553 

physical causes of 657 

preceded by frightful dreams 237 

prognosis of 669 

puerperal 640 

senile 100 

simultaneous (folie simultanec). . . 515 

state of the viscera in 685 

sunstroke as a cause of 666 

the countenance in 684 

the speech in 684 

treatment of 718 

wounds as causes of 663 

Insanity and genius, discrimination be- 
tween 49 

Instances of eccentricity 41 

Instances of habit 57 



PAGE 

Instances of idiosyncrasy 45 

Instinct, arrest of 131 

curious circumstance connected 

with 140 

definitions of 125 

impossibility to improve 139 

infallibility of 132 

lost 140 

manifestations of 132 

nature of 122 

of generation in frogs 147 

of plants 142 

seat of 147 

seat of, not in the brain 143 

unerring character of 142 

Instinct and automatic reaction, differ- 
ence between 133 

Instinct and reason, difference between. 134 

Instinctive actions 128 

Instinctive acts, qualities connected 

with 137 

Instinctive dispositions 131 

Instincts of idiots 149 

Intellect 20 

in acute mania, clearness of 542 

faculties of 21 

Intellectual causes of insanity 656 

Intellectual impulsions 387 

Intellectual insanities 292, 670 

Intellectual mania, chronic 354 

Intellectual monomania with depres- 
sion 340 

diagnosis of 687 

pathology and morbid anatomy of. 692 

prognosis of 673 

Intellectual monomania with exalta- 
tion, diagnosis of 687 

pathology and morbid anatomy 

of 692 

Intellectual objective morbid impulses. 389 

prognosis of 673 

Intellectual power of reasoning ma- 
niacs 377 

Intellectual subjective morbid impulses. 381 

prognosis of 673 

Intellectual subjective and objective 
morbid impulses, pathological 

anatomy of 699 

Intense emotion a cause of insanity. . . 25 

Interval, lucid 279 

Intricate mental processes during sleep. 199 
Irregularities of mind 38 



INDEX. 



763 



PAGK 

Jealousy as a cause of insanity 410 

Judgment, during sleep, exercise of . . . 193 

Katatonia 576 

pathological anatomy 705 

prognosis of 672 

Kleptomania 432 

Latent force in aboulomania 531 

Length of human life 88 

Life, length of human 88 

stages of 89 

Littleness, delirium of 484 

Location of the will 32 

Loquacity and incoherence in acute ma- 
nia 550 

Lower animals, emotions in 23 

Lowest weight of the human brain. ... 14 

\ Lucid interval 279 

Lunatics, fractured ribs in 547 

mental tasks for 740 

physical occupation for 741 

Lycanthropy 507 

Lymphatic temperament, the 65 

Macromaniacal delirium 485 

Malaria as a cause of insanity 668 

Male and female brain, differences be- 
tween the 103 

Mania, acute 535 

characteristics of hysterical 486 

- chronic intellectual 354 

dancing, or tarentism 513 

disposition to deceive in hysterical 495 
hallucinations incident to hyster- 
ical 494 

homicidal 441 

hypochondriacal 475 

hysterical 485 

in men hysterical 502 

periods of hysterical 492 

phases of hysterical 490, 491 

reasoning 362 

spontaneity of hysterical 488 

transitory 522 

Maniacs, illusions of hypochondriacal. 477 

Manifestations of instinct 132 

Marriages, consanguineous 85 

Masked epilepsy 631 

Masturbation as a cause of insanity. . . 667 
Maternal mind, influence over offspring 

before birth upon the 77 



PAGK 

Maturity, insanity during the period of 98 

period of 96 

Means of producing stupor 155 

Mechanical treatment of insanity 724 

Mechanism of the development of the 

emotions 26 

Medicinal treatment of insanity 744 

Medicines as causes of insanity 661 

Melancholia in general paralysis 609 

physical symptoms of 456 

prognosis of 673 

remarkable symptom of 468 

simple 454 

Melancholia with delirium 460 

duration of 471 

hallucinations incident to 461 

pathological anatomy of 700 

Melancholia with stupor 471 

pathological anatomy of 701 

Memory in sleep 192 

Men, hysterical mania in 502 

Menstrual cessation, abnormal tenden- 
cies excited by 112 

Menstrual discharge, period of the ces- 
sation of the 110 

Menstruation, abnormal mental condi- 
tion during 108 

a curative agent of nervous disor- 
ders 109 

in acute mania 546 

mental derangement at the begin- 
ning of 105 

nervous perversions caused by. . . Ill 
Mental aberration, causes tending to 
make it more common in men 

than in women 117 

Mental alienation during pregnancy.. . 115 
Mental and physical conditions influenc- 
ing the action of the mind. .... 34 
Mental condition during menstruation, 

abnormal 108 

Mental derangement at the beginning 

of menstruation 105 

in different races, liability to 120 

pride and vanity as subjects of. . . 407 

Mental development, arrest of 293 

Mental disease, methods to be employed 

in the classification of 285 

Mental factors, disturbing 37 

Mental operations of genius 48 

Mental processes during sleep, intri- 
cate 199 



764 



INDEX. 



PAGB 

Mental symptoms of general paralysis. 599 

Mental tasks for lunatics 740 

Methods to be employed in the classifi- 
cation of mental disease 285 

Microcephaly, case of 14 

Mind and brain, connection between. . 10 

Mind, definition of 9 

divisions of 15 

during sleep, state of the 183 

influence of dreams upon the. ... 249 

irregularities of 38 

nature and seat of 9 

Modification of constitutional defects. 74 

Monomania, ambitious 332 

emotional 401 

religious 332 

with depression, intellectual 340 

with exaltation, prognosis of 673 

Monophobia 424 

Moral treatment of insanity • • • . 729 

Morbid anatomy of general paralysis. . 710 

Morbid dreams 234 

essential .... 250 

treatment of 258 

Morbid impulse, imitation as a cause of. 398 

Morbid impulses, emotional 432 

Morbid impulses, intellectual objective. 389 

intellectual subjective 381 

volitional 517 

Morbid impulse to suicide, emotional. . 446 

Movements during sleep 182 

Muscular activity in acute mania 545 

Muscular sense 19 

Mysophobia 425 

Narcotics, influence upon the will 31 

Nature and seat of the mind 9 

Nature of instinct 122 

Necessity for sleep 174 

Necessity for sleep in infants 177 

Negation, delirium of 484 

Nervous disorders, menstruation a cura- 
tive agent of 109 

Nervous perversions caused by men- 
struation Ill 

Nervous temperament, examples of . . . 170 

Nervous temperament, the 69 

Neurosis, the psycho- 289 

Nightmare, causes of 257 

Nocturnal repose of plants 178 

Nostalgia 411 

Number of temperaments 62 



PAGB 

Nutrition in general paralysis 623 

Nymphomania in acute mania 551 

Occupation as a cause of insanity 667 

Odors, dreams produced by 226 

Panophobia 415 

Paralysis, general 596 

Paralysis of the will 524 

Pathological anatomy of aboulomania. . 702 

of acute mania. 703 

of choreic insanity 717 

of circular insanity 705 

of compound insanities. . 703 

of emotional insanities 699 

*±, of epidemic insanity 702 

of epileptic insanity 715 

of hebephrenia 704 

of hypochondriacal mania 701 

of hysterical mania 702 

of katatonia 705 

of melancholia with delirium 700 

of melancholia with stupor 701 

of pellagrous insanity 717 

of periodical insanity 704 

of primary dementia ... . 707 

of puerperal insanity 716 

of simple melancholia 700 

of intellectual subjective and ob- 
jective morbid impulses 699 

of volitional insanity 702 

Pathological phenomena during sleep. 182 
Pathology and morbid anatomy of 

chronic intellectual mania 697 

of hallucination 321 

of insanity 691 

of intellectual monomania with de- 
pression 692 

of intellectual monomania with ex- 
altation 692 

of reasoning mania 697 

Peculiarities, hereditary transmission 

of 75 

Peculiarities of race 119 

Pellagrous insanity 645 

pathological anatomy of 717 

prognosis of 672 

Perceptional insanities 292-294 

prognosis of 670, 672 

Perception and intellect, in relation to 

the will 32 

Perception, definition of 15 



INDEX. 



?65 



PAGE 

Perception the starting-point of all idea- 
tion 17 

Periodical insanity 553 

diagnosis of 688 

pathological anatomy of. 704 

prognosis of 674 

Period of decline 98 

conditions attending the 99 

Period of depression in circular in- 
sanity. 262 

Period of excitement in circular in- 
sanity 565 

Period of increase 90 

Period of insanity during pregnancy. . 115 
Period of labor in puerperal insanity. . 641 
Period of lactation in puerperal in- 
sanity 644 

Period of maturity 96 

Period of pregnancy in puerperal in- 
sanity 640 

Period of the cessation of the menstrual 

discharge 110 

Periods of hysterical mania 492 

Persecution, the delirium of 343 

Phases of hysterical mania 490, 491 

Phenomena of sleep, physical 178 

Phrenology 33 

Physical causes of insanity 657 

Physical occupation for lunatics 741 

Physical phenomena of sleep 178 

Physical symptoms of general paraly- 
sis 610 

of melancholia 456 

Physiology of dreams, the 210 

Plants, instinct of 142 

Plants, nocturnal repose of 178 

Poisonous secretions 37 

Power of attention, causes of diminish- 
ing the 172 

Predisposing causes of insanity 652 

Pregnancy in acute mania 546 

Pregnancy, mental alienation during. . 115 

period of insanity during 115 

Pride and vanity in relation to mental 

derangement 407 

Primary dementia 588 

diagnosis of 688 

pathological anatomy of 707 

prognosis of 674 

tendencies in 591 

Prodromic dreams 234 

Prognosis of acute mania 674 



PAGE 

Production of an emotion 25 

Production of hallucinations, voluntary 311 
Prognosis of chronic intellectual 

mania 673 

of compound insanities 671 

of constitutional insanities.. . 672, 674 

of emotional insanities 671 

of emotional monomania 673 

of emotional morbid impulses. ... 673 

of epidemic insanity 674 

of epileptic insanity 672 

of hebephrenia 672 

of hysterical mania 673 

of insanity 669 

of intellectual insanities 670 

of intellectual monomania with de- 
pression 673 

of intellectual objective morbid 

impulses 673 

of intellectual subjective morbid 

impulses 673 

of katatonia 672 

of melancholia 673 

of monomania with exaltation 673 

of pellagrous insanity 672 

of perceptional insanities 672 

of periodical insanity 674 

of primary dementia 674 

of reasoning mania 673 

of secondary dementia 674 

of senile dementia 674 

of simple melancholia 673 

of volitional insanities 671, 674 

Progressive muscular atrophy, diagno- 
sis of 689 

Psychical degenerations 289 

Psychical states of arrested develop- 
ment, idiocy, and cretinism 290 

Psycho-neuroses, the 289 

Puberty, insanity in boys during 113 

Puerperal insanity 640 

pathological anatomy of 716 

period of labor in 641 

period of lactation in 644 

period of pregnancy in 640 

Pulse and respiration in acute mania. . 546 

Pyromania 438 

Pyrophobia 431 

Qualities connected with instinctive 

acts 137 

Qualities, hereditary transmission of . . 75 



766 



INDEX. 



PAGE 

Race 117 

differences of 117 

peculiarities of 119 

Races, cranial capacity of several 119 

form of skull in different 120 

liability to mental derangement in 

several 120 

weight of brain in several 120 

Rational and instinctive actions, line 

between 129 

Reasoning mania 362 

diagnosis of 688 

pathology and morbid anatomy 

of ". 697 

prognosis pi 673 

Reasoning maniacs, bodily peculiarities 

of 378 

intellectual power of 377 

Regulation of habits 59 

Relation of the will to intellect and 

perception 32 

Religious monomania 332 

Remissions in the intensity of general 

paralysis 626 

Repose of plants, nocturnal 177 

Reproductive sense 20 

Respiratory sense 20 

Ribs in lunatics, fractured 547 

Sanguine temperament, examples of. . 64 

the 63 

Satyriasis in acute mania 551 

Seat of instinct 147 

Scat of instinct not in the brain 143 

Seat of the emotions 22 

Seat of the emotions in the brain 23 

Secondary dementia 593 

prognosis of 674 

Secretions, poisonous 37 

Senile dementia 594 

prognosis of 674 

Senile insanity 100 

Sense, muscular 19 

Sense of hearing in general paralysis. 622 

Sense of taste in general paralysis. . . . 622 

Sex 101 

Sexes, weight of body in the two 102 

Sex of child a determining cause of in- 
sanity in the mother 116 

Sexual characteristics 101 

Sight, hallucinations of 308 

illusions of 295 



PAGE 

Simple melancholia. . . 454 

pathological anatomy of 700 

prognosis of , 673 

Simultaneous insanity (folie simulta- 

nee) 515 

Size of the brain 13 

Sleep 151 

caused by cold 169 

caused by heat 169 

causes of 151 

conditions of the brain during. . . 162 
condition of the cerebral circula- 
tion during 164 

desire during 209 

difference between the exciting 
and the immediate cause of . . . . 152 

digestion leading to 173 

exercise of judgment during 193 

exercise of the will during 202 

influence of carotid compression 

in inducing 160 

in infants, necessity for 177 

intricate mental processes during. 199 

memory in 192 

movements during 182 

pathological phenomena during. . . 182 

physical phenomena of 178 

produced by debility 173 

produced by loss of blood 173 

state of the mind during 183 

the imagination during 190 

the necessity for 174 

vascular condition of the brain 

during 161 

Sleep-producing agents 156 

Smell, hallucinations of 310 

Spaces, fear of 419 

Speech in insanity 684 

Spermatophobia 432 

Spontaneity of hysterical mania 488 

Stages of life 89 

State of the mind during sleep 183 

State of the viscera in insanity 685 

Stupor and sleep, differences between. 155 

Stupor, means of producing 155 

melancholia with 471 

Suicide, emotional morbid impulse to. . 446 

Suicide in children 92 

Sunstroke as a cause of insanity 666 

Suspension of the will 31 

Symptomatic dreams 247 

Symptoms of acute mania 533 



INDEX. 



767 



PAGE 

Symptoms of melancholia, physical 456 

Syphilophobia 432 

Tarentism, or dancing mania 513 

Taste and smell, illusions of 301 

Temperament 60 

and constitution, difference be- 
tween 72 

the choleric 67 

definition of 61 

the lymphatic 65 

the nervous 69 

the sanguine 63 

Temperaments, degenerations of 71 

number of 62 

Temperature in acute mania 546 

Temperature of the body in general 

paralysis 623 

Tendencies excited by menstrual cessa- 
tion, abnormal 112 

Tendencies in primary dementia 591 

Tendency to disease increased by civili- 
zation , 120 

Theomania 507 

Thirst 19 

Tiring the brain, ways of 171 

Touch, hallucinations of 310 

Touch, illusions of 298 

Transitory mania 522 

Transmission of habit 56 

Treatment of insanity 718 

Treatment of morbid dreams 258' 

Two distinct forms of eccentricitv 40 



PAGE 

Unerring character of instinct 142 

Variations of idiosyncrasies 44 

Vascular condition of the brain during 

sleep , 161 

Volitional control, illustration of 27 

Volitional insanities 293, 517 

prognosis of 671, 674 

Volitional insanity, pathological an- 
atomy of 702 

Volitional morbid impulses 517 

Volition, exercise of 28 

Voluntary production of hallucinations 311 

Wakefulness in acute mania 549 

Ways of tiring the brain 171 

Weight of body in the two sexes 102 

Weight of brain in several races 120 

Weight of female brain 14 

Will and desire, difference between. . . 30 

Will, definition of 27 

Will during sleep, exercise of the 202 

Will in acute mania, the 545 

influence of narcotics upon the. . . 31 

influence of the . . , 27 

location of the 32 

paralysis of 524 

relation to intellect and percep- 
tion of the 32 

suspension of the . . 31 

Will power, inability to exert 31 

Wounds as causes of insanity 663 

Young persons, insanity in 95 



THE END. 



Medical and Hygienic Works 

PUBLISHED BY 

D. APPLETON & CO., i, 3, & 5 Bond St. y New York. 



PRICE 

ANSTIE (FRANCIS E.) Neuralgia and Diseases which resemble it. By 
Francis E. Anstie, M. D., F. R. 0. P., Senior Assistant Physician to 
Westminster Hospital ; Lecturer on Materia Medica in "Westminster 
Hospital School; and Physician to the Belgrave Hospital for Chil- 
dren ; editor of " The Practitioner " (London), etc. 12mo. . . Cloth, $2 50* 

BARKER (FORDYCE). On Sea-Sickness. A Popular Treatise for 
Travelers and the General Reader. By Fordyce Barker, M. D., 
Clinical Professor of Midwifery and Diseases of Women in the 
Bellevue Hospital Medical College, etc. Small 12mo Cloth, 75 

On Puerperal Disease. Clinical Lectures delivered at Bellevue 

Hospital. A Course of Lectures valuable alike to the Student and 

the Practitioner. Third edition. 8vo Cloth, $5.00* ; Sheep, 6 00* 

BARNES (ROBERT). Lectures on Obstetric Operations, including the 
Treatment of Hemorrhage, and forming a Guide to the Manage- 
ment of Difficult Labor. By Robert Barnes, M.D., F. R. C. P., 
Fellow and late Examiner in Midwifery at the Royal College of 
Physicians; Examiner in Midwifery at the Royal College of Sur- 
geons, London. 8vo. Third edition, revised and extended. Illus- 
trated , , Cloth, 4 50* 

BARTHOLOW'S Treatise on Materia Medica and Therapeutics. A 
new and revised edition. By Roberts Bartholow, M. A., M. D., 
Professor of Materia Medica and Therapeutics in the Jefferson Med- 
ical College ; late Professor of the Theory and Practice of Medicine, 
and of Clinical Medicine, and formerly Professor of Materia Medica 
and Therapeutics, in the Medical College of Ohio. Revised edition 
of 1879. 1 vol., 8vo. 548 pages Cloth, $5.00* ; Sheep, 6 00* 

A New and Practical Treatise on the Principles and Practice of 

Medicine. 8vo. Second edition, revised and enlarged. Cloth, $5.00*; 

Sheep, 6 00* 

On the Antagonism between Medicines and between Remedies 

and Diseases. Being the Cartwright Lectures for the Year 1880. 

8vo Cloth, 1 25* 

BASTIAN (H. CHARLTON, M. D., F. R. S.) On Paralysis from Brain- 
Disease in its Common Forms. 12mo Cloth, 1 75* 

The Brain as an Organ of the Mind 2 50 

BELLEVUE and CHARITY HOSPITAL REPORTS. Edited by Pro- 
fessor W. A. Hammond, M. D. 8vo 4 00* 

BENNET (J. H.) Winter and Spring on the Shores of the Mediterra- 
nean ; or, The Riviera, Mentone, Italy, Corsica, Sicily, Algeria, 
Spain, and Biarritz, as Winter Climates. By J. Henry Bennet, 
M. D., Member of the Royal College of Physicians, London. With 
numerous Illustrations. 12mo. New revised edition Cloth, 3 50* 

On the Treatment of Pulmonary Consumption, by Hygiene, Cli- 
mate, and Medicine. Thin 8vo Cloth, 1 50* 

BILLROTH (Dr. THEODOR). General Surgical Pathology and Thera- 
peutics. A Text-Book for Students and Physicians. By Dr. Theo- 
dor Billroth, Professor of Surgery in Vienna. From the eighth 
German edition, by special permission of the author, by Charles E. 
Hackley, M. D., Surgeon to the New York Eye and Ear Infirmary ; 
Physician to the New York Hospital. Fourth American edition, revised 
and enlarged. 1 vol., 8vo, , Cloth, $5.00* ; Sheep, 6 00* 



PftlCX 

BUCK (GURDON). Contributions to Reparative Surgery, showing its 
Application to the Treatment of Deformities produced by Destruc- 
• tive Disease or Injury ; Congenital Defects from Arrest or Excess 
of Development; and Cicatricial Contractions following Burns. 
Illustrated by Thirty Cases and fine Engravings. 8vo Cloth, $3 00* 

CARPENTER (W. B.) Principles of Mental Physiology, with their 
Application to the Training and Discipline of the Mind, and the 
Study of its Morbid Conditions. By William B. Carpenter, M. D., 
LL. D., F. R. S., F. L. S., F. G. S., Registrar of the University of 
London, etc. 12mo Cloth, 3 00 

CHAUVEAU (A.) The Comparative Anatomy of the Domesticated 
Animals. Translated and edited by George Fleming. 8vo. Illus- 
trated Cloth, 6 00 

COMBE (ANDREW). The Management of Infancy, Physiological and 
Moral. By Andrew Combe, M. D. Revised and edited by Sir 
James Clark, Bart., K. C. B., M. D., F. R. S. 12mo Cloth, 1 50 

COOLEY'S Cyclopaedia of Practical Receipts. A Comprehensive Sup- 
plement to the Pharmacopoeia, etc. Sixth edition. Revised and 
partly rewritten. By Richard V. Tuson, Professor of Chemistry. 
Two volumes. 8vo. Illustrated Cloth, 9 00 

CORFIELD (W. H.) Health. 12mo Cloth, 1 25 

DAVIS (HENRY G.) Conservative Surgery. With Illustrations. 

8vo Cloth, 3 00* 

ECKER (ALEXANDER). Convolutions of the Brain. Translated 

from the German by Robert T. Edes, M. D. 8vo Cloth, 1 25* 

ELLIOT (GEORGE T.) Obstetric Clinic : A Practical Contribution 
to the Study of Obstetrics, and the Diseases of Women and Chil- 
dren. By George T. Elliot, Jr., A. M., M. D. 8vo Cloth, 4 50* 

EVETZKY (ETIENNE, M. D.) The Physiological and Therapeutical 
Action of Ergot. Being the Joseph Mather Smith Prize Essay for 
1881. 1 vol., 8vo Limp cloth, 1 00* 

FLINT'S Manual of Chemical Examinations of the Urine in Disease; 
with Brief Directions for the Examination of the most Common 
Varieties of Urinary Calculi. By Austin Flint, Jr., M. D. Revised 

edition Cloth, 1 00* 

Physiology of Man. Designed to represent the existing state of 

Physiological Science as applied to the Functions of the Human 
Body. By Austin Flint, Jr., M. D., Professor of Physiology and 
Microscopy in the Bellevue Hospital Medical College, New York ; 
Fellow of the New York Academy of Medicine; Member of the 
Medical Society of the County of New York ; Resident Member of 
the Lyceum of Natural History in the City of New York, etc. Com- 
plete in 5 vols. 

Vol. 1. Introduction; The Blood; Circulation; Respiration. 8vo. 
Vol. 2. Alimentation; Digestion; Absorption; Lymph; and 

Chyle. 8vo. 
Vol.3. Secretion; Excretion; Ductless Glands ; Nutrition; Ani- 
mal Heat; Movements; Voice and Speech. 8vo. 
Vol. 4. The Nervous System. 8vo. 
Vol. 5. (With a General Index to the five volumes.) Special 

Senses; Generation. Per vol Cloth, $4.50* ; Sheep, 5 50* 

The five vols Cloth, $22.00* ; Sheep, 27 00* 

Text-Book of Human Physiology ; designed for the Use of Prac- 
titioners and Students of Medicine. Illustrated by three Litho- 
graphic Plates, and three hundred and thirteen Woodcuts. Third 
edition, revised. 1 vol., imperial 8vo Cloth, $6.00* ; Sheep, 7 00* 



s 

PRICE 

FLINT (A., Jr.) The Physiological Effects of Severe and Protracted 
Muscular Exercise ; with Special Reference to its Influence upon the 
Excretion of Nitrogen. By Austin Flint, Jr., M.D., etc. 12mo. . Cloth, $1 00 

— The Source of Muscular Power. Arguments and Conclusions 

drawn from Observation upon the Human Subject under Conditions 

of Rest and of Muscular Exercise. 12mo 1 00 

FOURNIER (ALFRED, M. D.) Syphilis and Marriage. Translated 

by P. Albert Morrow, M. D. 8vo Cloth, $2.00 ; Sheep, 3 00* 

FREY (HEINRICH). The Histology and Histochemistry of Man. A 
Treatise on the Elements of Composition and Structure of the 
Human Body. By Heinrich Frey, Professor of Medicine in Zurich. 
Translated from the fourth German edition by Arthur E. J. Barker, 
Surgeon to the City of Dublin Hospital ; Demonstrator of Anatomy, 
Royal College of Surgeons, Ireland ; Visiting Surgeon, Convalescent 
Home, Stillorgan ; and revised by the author. With 608 Engravings 
on Wood. 8vo Cloth, $5.00*; Sheep, 6 00* 

GAMGEE (JOHN). Yellow Fever a Nautical Disease. Its Origin and 

Prevention. 1 vol., 8vo Cloth, 1 50 

GROSS (SAMUEL W., M. D.) A Practical Treatise on Tumors of the 

Mammary Gland. 8vo. Illustrated 2 50* 

GUTMAN (EDWARD, M. D.) The Watering-Places and Mineral 

Springs of Germany, Austria, and Switzerland. Illustrated 2 50 

HAMILTON (ALLAN MoL., M. D.) Clinical Electro-Therapeutics, 
Medical and Surgical. A Hand-Book for Physicians in the Treat- 
ment of Nervous and other Diseases. 8vo Cloth, 2 00* 

HAMMOND (W. A.) A Treatise on Diseases of the Nervous System. 
By William A. Hammond, M. D., Surgeon-General U. S. Army (re- 
tired), Professor of Diseases of the Mind and Nervous System, in the 
Medical Department of the University of the City of New York, etc. 
Seventh edition, rewritten, enlarged, and improved. 8vo. 

Cloth, $5.00* ; Sheep, 6 00* 

A Treatise on Insanity {In active preparation.) 

Clinical Lectures on Diseases of the Nervous System. Delivered 

at Bellevue Hospital Medical College. Edited by T. M. B. Cross, 

M. D. 8vo Cloth, 3 50* 

HARVEY (A.) First Lines of Therapeutics. 12mo Cloth, 1 50* 

HEALTH PRIMERS. Edited by J. Langdon Down, M. D., F. R. C. P. ; 
Henry Power, M. B., F. R. C. S. ; J. Mortimer-Granville, M. D. ; 

John Tweedy, F. R. C. S. In square 16mo vols Cloth, each, 40 

1. Exercise and Training; 2. Alcohol: Its Use and Abuse; 3. The 
House and its Surroundings ; 4. Premature Death : Its Promotion or 
Prevention ; 5. Personal Appearance in Health and Disease ; 6. Baths 
and Bathing; 7. The Skin and its Troubles; 8. The Heart and its 
Functions ; 9. The Nervous System. 

HINTON'S Physiology for Practical Use. 12mo Cloth, 2 25 

HOFFMANN-ULTZMANN. Introduction to an Investigation of Urine, 
with Special Reference to Diseases of the Urinary Apparatus. By 
M. B. Hoffmann, Professor in the University of Gratz, and R. Ultz- 
mann, Tutor in the University of Vienna. Second enlarged and 

improved edition. 8vo Cloth, 2 00* 

HOFFMANN (FREDERICK, Ph. D,, Pharmaceutist in New York). 
Manual of Chemical Analysis, as applied to the Examination of 
Medicinal Chemicals. A Guide for the Determination of their 
Identity and Quality, and for the Detection of Impurities and Adul- 
terations. For the Use of Pharmaceutists, Physicians, Druggists, 

and Manufacturing Chemists, and Students Cloth, 3 00* 

HOSMER. The Every-day Doctor Full Roan, 3 00 



4 

PRICE 

HOLLAND (Sir HENEY, Bart., M. D.) Kecollections of Past Life. 

12mo Cloth, $2 00 

HOWE (JOSEPH W.) Emergencies, and How to Treat Them. By 
Joseph W. Howe, M. D., Visiting Surgeon to Charity Hospital ; 
Clinical Professor of Surgery in the Medical Department of the 
University of New York, etc. 8vo Cloth, 2 50* 

The Breath, and the Diseases which give it a Fetid Odor. With 

Directions for Treatment. 12mo Cloth, 1 00 

HUNTER (JAMES B., M. D.) A Manual of Gynecological Operations. 

With Illustrations {In preparation.) 

HUXLEY (T. H., LL. D.) The Anatomy of Yertebrated Animals. 

12mo. Illustrated Cloth, 2 50 

The Anatomy of Invertebrated Animals. 12mo. Illustrated. 

Cloth, 2 50 
HUXLEY and YOUMANS'S Elements of Physiology and Hygiene. 

By T. H. Huxley and W. J. Youmans. 12mo 1 75 

JOHNSTON'S Chemistry of Common Life. Illustrated. 12mo. Cloth, 2 00 

KEYES. The Tonic Treatment of Syphilis, including Local Treatment 
of Lesions. By E. L. Keyes, Adjunct Professor of Surgery, and 
Professor of Dermatology, B. H. M. C, and Surgeon to Bellevue 
Hospital. 8vo Cloth, 1 00* 

KINGSLEY (N. W., M. D.) A Treatise on Oral Deformities as a 
Branch of Mechanical Surgery. With over 350 Illustrations. 8vo. 

Cloth, $5.00* ; Sheep, 6 00* 
LEGG (J. WICKHAM, M. D.) On the Bile, Jaundice, and Bilious 
Diseases. With Illustrations in Chromo-Lithography. 8vo. 

Cloth, $6.00* ; Sheep, 7 00* 
LETTERMAN (J., M. D.) Medical Recollections of the Army of the 

Potomac. 8vo Cloth, 1 00 

LEWES'S Physiology of Common Life. 2 vols., 12mo Cloth, 3 00 

LINDSAY (W. L.) Mind in the Lower Animals. 2 vols., 8vo. Cloth, 4 00 

LUSK (WILLIAM T., M. D.) The Science and Art of Midwifery. 

Complete in 1 vol., 8vo. With 226 Illustrations. 

Cloth, $5.00* ; Sheep, 6 00* 
LUYS (J., Physician to the Hospice de la Salpetriere.) The Brain and 

its Functions. With Illustrations. 12mo Cloth, 1 50 

MARKOE (T. M.) A Treatise on Diseases of the Bones. By Thomas 
M. Markoe, M. D., Professor of Surgery in the College of Physicians 
and Surgeons. With Illustrations. 8vo Cloth, 4 50* 

MAUDSLEY (HENRY). Body and Mind : an Inquiry into their Con- 
nection and Mutual Influence, specially in reference to Mental 
Disorders. An enlarged and revised edition, to which are added 
Psychological Essays. By Henry Maudsley, M. D., London, Fellow 
of the Royal College of Physicians ; Professor of Medical Jurispru- 
dence in University College, London, etc. 12mo Cloth, 1 50 

Physiology of the Mind. Being the first part of a third edition, 

revised, enlarged, and in great part rewritten, of " The Physiology 

and Pathology of the Mind." 12mo Cloth, 2 00 

Pathology of the Mind. Third edition. 12mo .......... Cloth, 2 00 

Responsibility in Mental Disease. {International Scientific Series.) 

12mo Cloth, 1 50 

MoSHERRY. Health and How to Promote it Cloth, 1 25 

NEFTEL (WM. B., M. D.) Galvano-Therapeutics. The Physiological 
and Therapeutical Action of the Galvanic Current upon the Acoustic, 
Optic, Sympathetic, and Pneumogastric Nerves. 12mo Cloth, 1 50* 



5 

PRICE 

NEUMANN (ISIDOR). Hand-Book of Skin Diseases. By Dr. Isidor 
Neumann. Translated by Lucius D. Bulkley, A.M.., M. D. Illus- 
trated by 66 Wood Engravings. 8vo Cloth, $4.00* ; Sheep, $5 00* 

THE NEW YORK MEDICAL JOURNAL. Edited by Frank P. 

Foster, M. D Terms per annum, 5 00* 

NIEMEYER (Dr. FELIX YON). A Text-Book of Practical Medicine, 
with particular reference to Physiology and Pathological Anatomy. 
Containing all the author's Additions and Revisions in the eighth 
and last German edition. Translated from the German edition, by 
George H. Humphreys, M. D., and Charles E. Hackley, M. D. 2 
vols., 8vo. Edition of 1880 Cloth, $9.90* ; Sheep, 11 00* 

NIGHTINGALE'S (FLORENCE) Notes on Nursing. 12mo Cloth 75 

PAGET. Clinical Lectures and Essays. By Sir James Paget, Bart., 
F. R. S., D. C. L., Oxon., LL. D., Cantab., etc. Edited by Howard 
Marsh, F. R. C. S., etc. 8vo Cloth, 5 00* 

PEASLEE (E. R.) A Treatise on Ovarian Tumors; their Pathology, 
Diagnosis, and Treatment, with reference especially to Ovariotomy. 
By E. R. Peaslee, M. D., LL. D., Professor of Diseases of Women, in 
Dartmouth College ; formerly Professor of Obstetrics and Diseases 
of Women, in the New York Medical College ; Corresponding Mem- 
ber of the Obstetrical Society of Berlin, etc. In one large vol., 8vo. 
With Illustrations Cloth, $5.00* ; Sheep, 6 00* 

PEREIRA'S (Dr.) Elements of Materia Medica and Therapeutics. 
Abridged and adapted for the Use of Medical and Pharmaceutical 
Practitioners and Students, and comprising all the Medicines of the 
British Pharmacopoeia, with such others as are frequently ordered 
in Prescriptions, or required by the Physician. Edited by Robert 
Bentley and Theophilus Redwood. New edition. Royal 8vo. 

Cloth, $7.00* ; Sheep, 8 00* 

QUAIN. A Dictionary of Medicine. Edited by Richard Quain, M. D., 

F. R. S. ; assisted by numerous Eminent Writers. 8vo. . . .{In preparation.) 

RANNEY (AMBROSE L.) Applied Anatomy of the Nervous System, 
being a Study of this Portion of the Human Body from a Stand- 
point of its General Interest and Practical Utility, designed for Use 
as a Text- Book and as a Work of Reference. 8vo. 

Cloth, $4.00*; Sheep, 5 00* 

RIBOT (TH.) Diseases of Memory : an Essay in the Positive Psychol- 
ogy. Translated from the French by William Huntington. {In- 
ternational Scientific Series.) 12mo Cloth, 1 50 

RICHARDSON. Diseases of Modern Life. By Benjamin Ward Rich- 
ardson, M. D., M. A., F. R. S. 12mo Cloth, 2 00 

A Ministry of Health. 12mo , Cloth, 1 50 

ROSENTHAL (I.) General Physiology of Muscles and Nerves. With 

75 Woodcuts. 12mo Cloth, 1 50 

ROSCOE-SCHORLEMMER. Treatise on Chemistry. 

Vol. 1. Non-Metallic Elements. 8vo Cloth, 5 00 

Vol. 2. Part I. Metals. 8vo Cloth, 3 00 

Vol. 2. Part II. Metals. 8vo Cloth, 3 00 

SAYRE (LEWIS A., M. D.) Practical Manual of the Treatment of 
Club-Foot. By Lewis A. Sayre, M. D., Professor of Orthopedic 
Surgery in the Bellevue Hospital Medical College; Surgeon to 
Bellevue Hospital, etc. New edition. 12mo Cloth, 1 25 

Lectures on Orthopedic Surgery and Diseases of the Joints, de- 
livered at Bellevue Hospital Medical College, during the Winter 
Session of 1874-1875, by Lewis A. Savre, M. D. 

Cloth, $5.00* ; Sheep, 6 00* 



6 

PRICE 

SCHROEDER (Dr. KARL). A Manual of Midwifery, including the 
Pathology of Pregnancy and the Puerperal State". By Dr. Karl 
Schroeder, Professor of Midwifery, and Director of the Lying-in 
Institution, in the University of Erlangen. Translated into English 
from the third German edition, by Charles H. Carter, B. A., M. D., 
B. S., London ; Member of the Royal College of Physicians, London' 
etc. With 26 Engravings on Wood. 8vo. . .Cloth, $3.50*; Sheep', $4 50* 

SIMPSON (Sir JAMES Y.) Selected Works: Anaesthesia, Diseases of 

Women. 3 vols., 8vo. Per volume Cloth, $3.00* ; Sheep, 4 00* 

SMITH (EDWARD, M. D., LL. B., F. R. S.) Foods. {International 

Scientific Series.) \ 75 

Health : a Hand-Book for Households and Schools. 12mo. Cloth, 1 00 

STEINER. Compendium of Children's Diseases: a Hand-Book for 
Practitioners and Students. By Dr. Johannes Steiner, Professor of 
Diseases of Children in the University of Prague, etc. Translated 
from the second German edition, by Lawson Tait, F. R. C. S., etc. 
8vo Cloth, $3.50* ; Sheep, 4 50* 

SWETT'S Diseases of the Chest. 8vo Cloth, 3 50* 

TYNDALL (JOHN). Essays on the Floating Matter of the Air ; in 

Relation to Putrefaction and Infection. 12mo Cloth, 1 50 

VAN BUREN (W. H.) Lectures upon Diseases of the Rectum, and 
the Surgery of the Lower Bowel, delivered at Bellevue Hospital 
Medical College; by W. H. Van Buren, M. D., LL. D., Professor of 
the Principles and Practice of Surgery in the Bellevue Hospital 
Medical College ; one of the Consulting Surgeons of the New York 
Hospital ; of the Bellevue Hospital ; Member of the New York 
Academy of Medicine ; of the Pathological Society of New York, 
etc. New edition, enlarged and rewritten. 8vo Cloth, 3 00* 

VAN BUREN and KEYES. A Practical Treatise on the Surgical 
Diseases of the Genito-Urinary Organs, including Syphilis. De- 
signed as a Manual for Students and Practitioners. With Engrav- 
ings and Cases. By W. H. Van Buren, M. D., LL. D., and Edward 
L. Keyes, A. M., M. D., Professor of Dermatology in Bellevue Hos- 
pital Medical College ; Surgeon to the Charity Hospital, Venereal 
Division ; Consulting Dermatologist to the Bureau of Out-Door 
Relief, Bellevue Hospital, etc. 8vo Cloth, $5.00* ; Sheep, 6 00* 

VOGEL (A.) A Practical Treatise on the Diseases of Children. By 
Alfred Vogel, M. D., Professor of Clinical Medicine in the Univer- 
sity of Dorpat, Russia. Translated and edited by H. Raphael, M. D., 
late House Surgeon to Bellevue Hospital ; Attending Physician to 
the Eastern Dispensary for the Diseases of Children, etc. From the 
fourth German edition. Illustrated by six Lithographic Plates. 8vo. 

Cloth, $4.50*; Sheep, 5 50* 

WAGNER (RUDOLF). Hand-Book of Chemical Technology. Trans- 
lated and edited from the eighth German edition, with extensive 
Additions, by William Crookes, F. R. S. With 836 Illustrations. 
8vo, 761 pages Cloth, 5 00 

WALTON (GEORGE E., M. D.) Mineral Springs of the United States 
and Canadas. Containing the latest Analyses, with full Description 
of Localities, Routes, etc. 12mo Cloth, 2 00 

WELLS (Dr. T. SPENCER). Diseases of the Ovaries. 8vo Cloth, 4 50 

WYLIE (WILLIAM G.) Hospitals 2 50* 



The Popular Science Monthly. 

Conducted by E. L. & W. J. YOUMANS. 



This magazine draws from the intellectual resources of all nations, and is now recog- 
nized as the most successful scientific periodical in the world. 

It is widely taken by the cultivators of science in all branches, particularly by physi- 
cians, who find it indispensable, and are extensively enumerated among its subscribers. 

The reason of this is, that our best minds are getting tired of the shallow frivolities 
of sensational literature, and demand a magazine that elevates the standard of popular 
reading in this country. Science is the great agency of improvement in this age, private 
and public, individual, social, professional, and industrial. In its irresistible progress it 
touches everywhere, and affects everybody. It gives law to the material interests of the 
community, and modifies its ideas, opinions, and beliefs, so that all have an interest in 
being informed of its advancement. Those, therefore, who desire to know what is going 
on in the world of thought in these stirring times, when new knowledge is rapidly extend 
ing, and old errors are giving way, will find that they can only keep posted by subscribing 
for The Popular Science Monthly. 



WHAT IS SAID OF IT. 

" This is one of the very best periodicals of its kind published in the world. Its corps 
of contributors comprise many of the ablest minds known to science and literature." — 
American Medical Journal, St. Louis. 

" The Popular Science Monthly fills an unsupplied want. We can not well under- 
stand why an intelligent layman can dispense with it ; certainly this journal should be the 
monthly visitant of every physician and scientist." — Virginia Medical Monthly. 

" Each month it provides some one hundred and fifty pages of choice reading, often 
original, and always valuable, no less than invitingly interesting." — Saturday Evening 
Lzpres, Boston, Mass. 

" The Monthly is a periodical that thoughtful readers will not willingly do without." 
— Louisville Courier-Journal. 

" Outside of medical journals, there is no periodical published in America as well 
worthy of being placed upon the physician's library-table and regularly read by him as 
The Popular Science Monthly." — St. Louis Clinical Record. 

" Every physician's table should bear this valuable monthly, which we believe to be 
one of the most interesting and instructive of the periodicals now published, and one 
which is destined to play a large part in the mental development of the laity of this 
country." — Canadian Journal of Medical Science. 

" This magazine is rapidly gaining in popular confidence and in circulation." — Brook- 
lyn (Yl Y.) Union -Argus. 

" A journal of eminent value to the cause of popular education in this country." — 
New York Tribune. 

The volumes begin in May and November of each year. Subscriptions may begin at 
any time. Terms, $5.00 per annum ; single number, 50 cents. 

A club of five will be sent as directed for $20.00 per annum. 

The Popular Science Monthly and New York Medical Journal, to one address, 
$9.00 per annum. Full price, $10.00. 

A General Index to The Popular Science Monthly, from its first issue to April, 1882 
— twenty volumes — price, cloth bound, $1.00. 

D. APPLETON & CO., Publishers, 

1, 3, & 5 Bond Street, New Yoris 



THE 



NEW YORK MEDICAL JOURNAL, 

A Weekly Review of Medicine. 
Edited by FRANK P. FOSTER, M. D., 

ASSISTANT 6UBGEON TO THE WOMAN'S HOSPITAL. 



The New York Medical Journal, now in its thirty-seventh volume, is published 
every Saturday. It is handsomely printed, in large, double-columned pages, containing a 
large amount of carefully selected matter relating to all the departments of medicine. 

Its contents consist of 
Lectures and Addresses, by College Professors and Hospital Physicians and Surgeons. 
Original Communications, for the most part practical in character. 
Clinical Reports of Hospital and Dispensary Practice. 
Correspondence. 
Book Notices. 
Editorial Articles. 

Proceedings of Societies, including selected reports of the New York Academy of Medi- 
cine, the Medical Society of the County of New York, the New York Pathological 
Society, the New York Dermatol ogical Society, etc. ; official reports (published in 
this Journal only) of the New York Obstetrical Society, the New York Society of 
German Physicians, the New York Clinical Society, etc. ; reports of other societies 
from time to time. 

Reports on the Progress op Medicine : separate reports quarterly on Anatomy and 
Physiology ; General Medicine ; Surgery ; Obstetrics and Gynaecology, Materia 
Medica, Therapeutics, and Toxicology ; Ophthalmology and Otology ; Venereal 
and Genito-Urinary Diseases ; Orthopaedic Surgery ; Dermatology ; Psychological 
Medicine ; and Preventive Medicine. 

Miscellany. 



A new volume of the New York Medical Journal begins with the first number for 
January and July of each year. 

Terms, $5.00 per annum (postage prepaid by the Publishers) ; 
single copies, 15 cents. 

The New York Medical Journal and The Popular Science Monthly, to one ad- 
dress, $9.00 per annum. 

A General Index to the New York Medical Journal, from its first issue to June, 
1876 — including twenty-three volumes— now ready. Bound in cloth, price, 75 cents. 



New York: D. APPLETON" & CO., 1, 3, & 5 Bond Street. 



